In this video, we demonstrate how to place a MILA chest tube. The dog in this video sustained severe internal crushing injuries to the chest and abdomen from being rolled over by both the front tire and back tire of a vehicle. This resulted in massive hemorrhage into the thoracic and abdominal cavities, hypovolemic shock, and respiratory distress. Bilateral MILA chest tubes were placed so that the blood in the chest cavity could be drained. The purpose of this was twofold: to alleviate respiratory distress (the amount of blood in the chest cavity was causing the lungs to collapse), and to acquire blood to be used for autotransfusion. The patient made a complete recovery, and one month later she was back to going for 3 hour hikes in the mountains.
Overview and Indications:
Chest tubes are used to enable fluid (pleural effusion) or air (pneumothorax) that has accumulated between the lungs and chest wall to be intermittently or continuously suctioning from the chest cavity, without having to introduce a needle into the chest cavity each time.
How to Place a Thoracostomy Tube (Chest Tube) : Step by Step
Prepare your supplies:
Start by getting all of your supplies out and ready to go. Remember to label any syringes containing drugs and medications.
|-Clippers and surgical scrub|
|-Lidocaine for local anesthetic||usually 1-2 mL depending on patient size; I prefer a 25 ga needle to minimize discomfort|
|-A marker or sharpie|
|-Sterile gloves (for you) and regular/nitrile gloves (for your assistant)|
|– MILA Chest Tube Kit
|I prefer :
|-A three-way stopcock or one-way valve|
|-60- ml syringe (or smaller if the patient is tiny)|
|– If pleural effusion is present] sample tubes labeled “effusion” for fluid analysis/cytology (lavender/ EDTA tube) and culture.||**If the effusion looks hemorrhagic, collect it aseptically into 60 cc syringes and keep close by in case you need it for autotransfusion.|
|-Sterile drape||It is ideal to drape the site, although not everyone does.|
Attach the extension set to the three-way stopcock and syringe, and ensure that all of the connections are very secure. Make sure that your assistant knows how to operate the three-way stopcock.
Select Site, Clip Fur, and Infuse Local Anesthetic
Start by selecting the optimal intercostal space for centesis/chest tube placement; this is most easily accomplished using ultrasound. You can also use your stethoscope.
Chest tubes are usually placed so that they enter the chest cavity at approximately the 8th intercostal space (7-9th). When counting rib spaces, ually start at the caudalmost rib (13th) and count backwards until I reach the 8th intercostal space. Another shortcut to finding the 8th intercostal space is to imagine a ribbon around the chest cavity at the level of the xyphoid process (the last sternebra), and trace this line until you reach the lateral thorax.
Important: Have an assistant pull the patient’s skin on that side cranially at least 1 rib space until the tube has been placed. After the tube has been placed, the skin will be allowed to recoil to its normal spot, which ensures that the chest tube tunnels beneath the skin a few inches before entering the chest cavity. This minimizes the risk of fluid or air leaking around the tube.
If you are alleviating a pleural effusion, the chest tube is introduced in the ventral 1/3 (gravity-dependent) of the thorax. For pneumothorax, the chest tube is introduced in the dorsal 1/3 of the thorax.
Generously clip the selected site (from approximately the 3rd rib to the 11th rib). You may need to do the opposite side.
I like to circle my optimal centesis site (identified by ultrasound) with a sharpie, and then infiltrate local anesthetic into that area, making sure that I go deep enough into the intercostal musculature to minimize discomfort as I pass the needle through the chest wall.
Aseptically scrub the site and put your sterile gloves on.
Introducing the “introducing catheter”:
The kit comes with an introducing catheter, which looks like a large bore IV catheter. Advancing the “introducing catheter” is the first step. At the selected intercostal space, remember that you will want to advance your catheter along the cranial aspect of the caudal rib to avoid the vessels and nerves that run along the caudal aspect of the ribs. You can begin to slowly advance the needle through the skin, and then continue creeping along the cranial aspect of the rib. If you feel a gentle scratch on the rib, that can help you gauge your depth as you are advancing the needle into the chest cavity.
It is generally recommended to direct the catheter so that the bevel of the stylet is parallel to the lung. I hold the needle lightly between my fingers to minimize the risk of lacerating lung.
Introduce the guidewire
Remove the introducing catheter’s stylet, and briefly occlude the catheter.
Feed the guide wire through the catheter far enough that you are sure that the guidewire is securely through the chest wall. Make sure that there is enough guidewire left on the outside of the chest wall that there is no risk of the the whole guidewire disappearing into the chest cavity.
Keeping the guidewire in place, remove the introducing catheter.
Introduce the MILA chest tube by guiding it over the guidewire and into the chest cavity.
As you do this, hold onto the guidewire so that it does not get drawn into the chest. Make sure that you advance the chest tube far enough that all of the fenestrations on the tube are within the chest cavity.
Remove the guidewire and quickly occlude the chest tube with a clamp. Ensure that it is correcly positioned and aspirates nicely.
Secure the chest tube:
Secure the chest tube in its optimal location (you may need to adjust) with the fasteners provided in the kit. You can take x-rays (orthoganal views!) to ensure correct placement.
Place a biocclusive over the site.
Most patients with chest tubes belong in 24 hour facilities that are fully equipped to manage chest tubes and address complications.
Some patients with severe pleural space disease may require continuous suction of their chest tubes. There are several devices for this, with pluero-vac being the most common.
General chest tube care:
- Always wear gloves when handling chest tube.
- Aspirate chest tube at regular intervals (minimally every 4 hours) as needed and record volumes. Ensure patency and position.
- Visualize the site, clean site with chlorhexidine, and change biocclusive at least once every 24h.