PERCUTANOUS TUBE THORACOSTOMY

Transcription

1 PERCUTANOUS TUBE THORACOSTOMY Suveer Singh BSc MBBS FRCP PhD EDIC BDICM Consultant Pulmonary and Critical Care Chelsea and Westminster Hospital London, UK September 2007

2 Anatomy of the Pleural Space Parietal Pleura Pleural Cavity Lung Visceral Pleura Lung Pleural Cavity Hilum Costa Diaphragmatic Sinus Costa Diaphragmatic Sinus FRONT VIEW Diaphragm LATERAL VIEW

3 Indications for TT PTX (spontaneous, iatrogenic, traumatic) Haemothorax Chylothorax Decreased breath sounds in unstable patient after blunt or penetrating trauma Multiple rib fractures, sucking chest wound, subcutaneous air in intubated trauma patient Complicated pleural effusion, empyema, lung abscess Thoracotomy, decortication Pleural lavage for active rewarming for hypothermia

4 Complications Undrained PTX, haemothorax, or effusion despite TT clotted hemothorax, empyema, fibrothorax Improper placement +/- iatrogenic injuries (lung, diaphragm, subclavian, right atrium) Recurrent PTX after tube removal Intrapleural collections following tube removal Thoracic empyema

5 Insertion

6 Lung Rib Intercostal Nerves and Vessels Intercostal Muscles Intercostal Space Fluid (or air) free in the pleural cavity Intercostal Space Diaphragm Diaphragm

7 Anatomy of the Pleural Space Ribs Intercostal Vessels Intercostal Space Diaphragm Collapsed Lung

8 Anatomy of the Pleural Space Ribs Fluid, free in the pleural cavity Lung

9 Loculated vs Free Pleural Effusion (Air or Liquid) Pleural Adhesions Loculated Effusion Fluid (or air) free in the pleural cavity

10 Loculated vs Free Pleural Effusion (Air or Liquid) Rib Lung Pleural Adhesion Pleural Adhesions Loculated Effusion Rib Pleural Adhesions Lung

11 Tube Placement Anterior Route 2 nd or 3 rd intercostal space on the mid-clavicular line (the 1 st intercostal space that is felt is the 2 nd ) 2 cm More than 2 cm outside the sternum to avoid the mammary artery For Pneumothoraces

12 Tube Placement Axillary Route Between the 3 rd and 5 th intercostal space on the mid axillary line (the 1 st rib that is felt is the 2 nd or 3 rd ) External edge of the pectoralis major Anterior edge of the latissimus dorsi Incision between the fibers of the serratus anterior 5 th intercostal space

13 Proper Tube Placement Major factor: the point of entry Minor factor: the direction of the guide Collection of air (free effusions)

14 Proper Tube Placement Major factor: the point of entry Minor factor: the direction of the guide Collection of liquid (free effusions)

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16 Seldinger Technique Method for introducing a catheter into a vessel via a needle puncture. The vessel is located with a special needle that contains a wire; the needle is removed. The catheter is threaded into the vein while being guided by the wire over which it is moving. The wire is then removed from the needle. Used in angiography, cardiac catheterization, and cannulation of the central venous system and potential spaces. Sven-Ivar Seldinger: Karolinska Institute Radiologist. Catheter replacement of the needle in percutaneous arteriography (a new technique). Acta Radiologica, Stockholm, 1953, 39:

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18 Seldinger Chest Drains Developed a better method of catheterisation struggling when i had "a severe attack of common sense": After an unsuccessful attempt to use this technique, I found myself, disappointed and sad, with three objects in my hand - a needle, a wire and a catheter - and... in a split second I realized in what sequence I should use them: Needle in, wire in, needle off, catheter on wire, catheter in, catheter advance, wire off". 1950's - routine procedure in radiological departments

19 Range available

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21 Heimlich Chest Drain adaptor

22 Seldinger Chest drains Pros/Cons Comfortable Easy to insert Underlying lung protection* Operator confidence in position Less chance of subcut emphysema? Ease of draining thick fluid/haemothorax

23 Seldinger Chest drains Prospective data 52 drains in 44 patients over 10 months 12 to 20F 64y +/ ± 0.5 days Pneumothorax 14 (27%) Malignant effusions 19 (37%), Empyema 10 (19%), Parapneumonic effusions 5 (10%), Other effusions 4 ( 8%) Horsely A et al; Chest 2006; 130:1857 Efficacy and Complications of Small-Bore, Wire-Guided Chest Drains

24 Seldinger Chest drains Prospective data Pain VAS - 3 to 66 mm (ave 23 ± 16 mm) overall drain failure 37% 1 empyema Success rates Malig effusion 83% Pneumothorax 64% Empyema 20% Good for uncomplicated effusions/ptx. Horsely A et al; Chest 2006; 130:1857 Efficacy and Complications of Small-Bore, Wire-Guided Chest Drains

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26 Safe Placement

27 Seldinger Chest drains Pros/Cons

28 Position Drain in oblique fissure blocked by lung tissue Lower chest CT showing tension pneumothorax

29 Chest tubes should be inserted so that the last hole of the drain is inside the thoracic cavity. However if passed too far into the chest, drains can cause severe intractable pain as they abut the mediastinum.

30 Simple pneumothorax

31 The hidden pneumothorax

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33 Which side is the pneumothorax?

34 Deep Sulcus Sign

35 Loculated vs Free Pleural Effusion (Air or Liquid) Left Loculated Empyema Left Loculated Empyema Loculated Pleural Effusions

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37 Tube Thoracostomy: Complications and the Role of Prophylactic Antibiotics

38 Indications for TT PTX (spontaneous, iatrogenic, traumatic) Haemothorax Chylothorax Dec breath sounds in unstable patient after trauma Multiple rib fractures, sucking chest wound, subcutaneous air in intubated trauma patient Complicated pleural effusion, empyema, lung abscess Thoracotomy, decortication Pleural lavage for active rewarming for hypothermia

39 Complications Undrained PTX, hemothorax, or effusion clotted hemothorax, empyema, fibrothorax Improper placement +/- iatrogenic injuries (lung, diaphragm, subclavian, right atrium) Recurrent PTX after tube removal Intrapleural collections following removal Thoracic empyema

40 Factors Influencing Complications: Louisville study Prior studies report TT complication rates of 3-36% Etoch SW, Bar-Natan MF, Miller FB, Richardson JD. Tube Thoracostomy: Factors related to complications. Arch Surg. 1995; 130: Retrospective chart review (U of Louisville) 379 trauma pts, 599 tubes

41 Factors Influencing Complications: Complications: Empyema Louisville study Undrained PTX or effusion Improper tube placement (+/- iatrogenic injury) Post-tube PTX Other Measures: Rate of complications ass d w/ TT setting, operator, patient characteristics, MOI, and severity of injury

42 Overall rate of complications 21% per patient (16% per tube) 8.2% of complications required thoracotomy

43 Factors Influencing Complications: Setting 48% of tubes placed in ED, 23% in OR, 12% in ICU, 7% on floor, and 9% at OSH prior to transfer Significantly higher complication rate when TT performed in outside hospital prior to transfer (33%, p<.0001) No significant difference in complication rates between TT in ED (9%) vs. TT in other areas of study hospital (7%)

44 Factors influencing Complications: Operator 59% placed by surgeons, 26% by ED physicians, 8% by physicians prior to transfer Highest complication rate - by physicians in outside hospitals, mostly nonsurgeons (38%) Complication rates for TT s in study hospital: 13% for ED physicians, 6% for surgeons (p<. 0001) For TT s in ED: 13% complication rate for ED physicians vs 5% complication rate for surgeons (p<.01)

45 Factors influencing Complications: Mechanism/Severity of Injury No difference in complication rate related to: Age and sex of patients Mechanism of injury (23% blunt vs 18% penetrating) ISS Significantly increased complications related to: ICU admission (29% vs 11%, p<.0001) Mechanical ventilation (29% vs 15%, p<.002) Hypotension (SBP<90) on adm(31% vs 17%, p<.003)

46 Factors Influencing Complications: University Hospital study Deneuville M. Morbidity of percutaneous tube thoracostomy in trauma patients. Eur J CT Surg. 2002; 22: Prospective observational study (University Hospital, Guadeloupe) 128 trauma pts, 134 tubes Non-thoracic operators vs. thoracic surgeons

47 Factors Influencing Complications: University Hospital study Overall complication rate 25% (29% per tube) 5 (12.8%) improper placement, no iatrogenic injury 4 (10.3%) improper placement w/ iatrogenic injury (lung x 2, diaphragm, subclavian artery) 4 (10.3%) undrained hemothorax/ptx 12 (30.8%) post-removal PTX 7 (18%) post-removal fluid collection 3 (2.3%) empyema 4 (10.3%) combined 18 (46.2%) of complications required surgery (thoracotomy or VATS)

48 Factors Influencing Complications: University Hospital study Significantly increased risk of complication related to: Polytrauma (RR 2.7, p<0.05) Need for assisted ventilation (RR 2.7, p<.003) TT by non-thoracic surgeons (RR 8.7, p<.0001 blunt trauma and RR 12.5%, p<.0001 penetrating trauma)

49 Thoracic Empyema Empyema occurred in 1.8% (Louisville) and 2.3% (University Hospital) of patients w TT Setting or operator NO DIFF Antibiotics within 24 hours of initial TT in Louisville study (2% vs 2%) NO DIFF

50 Prophylactic Antibiotics in TT: Does prophylactic antibiotic use in injured patients requiring TT reduce the incidence of empyema and/or pneumonia? Paucity of good studies, that control for setting, operator, mechanism of injury, timing of antibiotic administration, choice and dose of antibiotic, and duration of prophylaxis

51 Prophylactic Antibiotics in TT: EAST Guidelines Luchette FA, Barrie PS, Oswanski MF, Spain DA, Mullins CD, Palumbo F, Pasquale MD. Practice Management Guidelines for Prophylactic Antibiotic Use in Tube Thoracostomy for Traumatic Hemopneumothorax: the EAST Practice Management Guidelines Work Group. J Trauma. 2000; 48(4): MEDLINE search ( ) for references using query words: antibiotic prophylaxis, chest tubes, human, drainage, tube thoracostomy, infection, empyema, and bacterial infection-prevention and control. 11 articles reviewed: 9 prospective series, 2 metaanalyses

52 Prophylactic Antibiotics in TT: EAST Guidelines Articles classified by Agency for Health Care Policy and Research (AHCPR) methodology Class I: prospective, rand, d-b, controlled trials Class II: prospective, rand, non-blinded trial Class III: retrospective series or meta-analysis 4 class I, 5 class II, and 2 class III M-A

53 Prophylactic Antibiotics in TT: Conclusions and Recommendations Incidence of empyema (Plac v AB ) 0-18%, v 0-2.6% 2 class I studies incidence of empyema w/ antibiotic Rx (Cant, 1993; Grover, 1977) 2 class II studies - no benefit w/ antibiotics (Mandal, 1985; Demetriades, 1991) Incidence of pneumonia Plac v AB % v 0-12% Insufficient evidence to support prophylactic antibiotics as a standard of care for reducing incidence of empyema or pneumonia in patients requiring TT

54 Recommendations Additional training of all trauma physicians Early thoracotomy or VATS in settings of persistent fluid collection or multiple chest tube placements as means to prevent against development of empyema First generation cephalosporin for no more than 24 hours Further research!

55 Pleural Effusion All Patients with fluid + sepsis or pneumonia (or loculated) Don t forget ph, LDH > 500 (likely infected) If ph < 7.2 or pus or gram stain or culture: NEEDS DRAINAGE TO DRYNESS

56 Thrombolysis for Pleural Infection cochrane small RCTs Some favour in reducing defervesence, LOS, surgical intervention

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59 Not in pleural infection? in loculated malignant effusions Early discussion with thoracic surgeons MIST 2 - DNAse vs Thrombolysis v Standard care

60 Pneumothorax New Classific n Abandoned small/mod complete: Now: > / < 2cm lung edge

61 PTX GUIDE: PRIMARY?+suction -5kPa

62 PTX GUIDE: SECONDARY 1. check position 2. unblock 3.?+suction -5kPa

63 Failure to respond: Referral, Suction Discharge: Pneumothorax Management No air travel until >4/52 confirmed resolution Permanently avoid diving or definitive surgery Successful aspiration: observe 4-6hrs if primary, 24hrs if secondary

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