Chest Tube Insertion in the Neonate

Anatomy and Physiology

Neonates have unique thoracic anatomy compared to adults. Neonates have a supple chest wall and delicate lung tissue. Most importantly, neonates' mediastinal organs lie in close proximity to the chest. The lungs are protected by visceral pleurae, which prevent serous lung membranes from rubbing against the chest wall. The parietal pleurae line the chest wall and diaphragm. The region between the visceral and parietal pleurae forms a moistened space called the "pleural cavity." Air, exudate, chyle, or blood may enter the pleural cavity and cause pathology. A thoracostomy can evacuate these substances, leading to symptom resolution.[3] Draining the fluid in the pleural space allows the lung to maximally reexpand and directly press against the chest wall for optimal lung expansion and elimination of the pleural space.

The chest wall is composed of the ribs and the external, internal, and innermost intercostal muscles. Directly under each rib, between the innermost and internal intercostal muscles, lies a neurovascular bundle comprised of the intercostal artery, nerve, and vein.[4] The intercostal space refers to the region between each rib. Avoiding the neurovascular bundle is crucial. Thus, the chest tube is inserted over the inferior rib during placement.

Before placing a chest tube, the clinician should become familiar with neonatal thoracic anatomy as it changes during the respiratory cycle. The phrenic nerves innervate the diaphragm. Diaphragmatic contraction creates negative intrathoracic pressure, allowing the lungs to expand and relax during expiration. The diaphragm has sulci and is dome-shaped bilaterally. Thus, the 3-dimensional intrathoracic space changes with each inspiration and expiration.

If chest tubes are placed too low, they are at risk of entering both the pleural and intraabdominal spaces, depending on the rib insertion location. Certain conditions can make the diaphragm rise higher than normal, including diaphragmatic paralysis, paresis, and hernias, and significant intestinal or abdominal distention. Diaphragmatic hernias should be approached with extreme caution since intraabdominal contents may enter the thorax and perforate.[5] Additionally, any patient who previously had a chest tube, pleurodesis, pleural infection or empyema, chest trauma, and cardiothoracic surgery should be referred to a surgeon for chest tube placement, as significant adhesions can cause the lung parenchyma to adhere to the chest wall and obliterate the pleural space. In these challenging cases, going to the operating room for video-assisted camera ports or a thoracotomy may be indicated.

Indications

Chest tube placement has multiple indications in the neonatal population. Similar to adult patients, a chest tube in the neonate may serve to remove air or fluid from the pleural space.[6] By doing so, the chest tube recreates negative pressure in the chest cavity and allows the lung to reexpand. The chest tube is less commonly used to direct fluids or medications into the pleural space.[7] In the setting of a tension pneumothorax, a chest tube placement is usually indicated following emergent needle decompression.

Removal of Fluid in the Pleural Space

Fluid occupying the lung space may similarly prevent lung expansion in the neonate patient. While different sources of fluids may arise from various causes, treatment with a chest tube to the affected lung remains the same. For instance, fluid collections during extracorporeal membrane oxygenation necessitate chest tube placement in the pediatric population. However, the procedure has also caused significant bleeding complications and death, particularly in this anticoagulated population.[8] Fluid hemothorax, particularly after congenital heart surgery or trauma, and pleural effusion are 2 additional causes of fluid development in the pleural space.[9] Similarly, a chylothorax, either from increased venous pressure or thrombosis, congenital malformation, or after congenital heart surgery, requires a chest tube to evacuate fluid in the pleural space, thereby allowing the lungs to re-expand.[10][11] Common congenital heart operations that may predispose to chylothorax include the Fontan operation or coarctation of the aorta via left thoracotomy.[12] Lastly, an empyema, or an infection in the pleural space leading to the development of pus, necessitates a chest tube for treatment and source control.[13]

Evacuation of Air from the Pleural Space

Pneumothorax may prevent lung expansion and occur frequently in the neonatal period. Additionally, neonatal pneumothorax is associated with high morbidity and mortality.[14] Air leaks in the neonate may arise from various sources, including respiratory distress syndrome, mechanical ventilation, bronchopleural fistula, meconium or amniotic fluid aspiration, and congenital malformations.

Clinical suspicion of a tension pneumothorax necessitates immediate chest tube placement for management.[15] A tension pneumothorax occurs when air significantly increases chest cavity pressure, preventing venous return and causing hypotension and hemodynamic collapse. Tension pneumothorax requires emergent needle decompression to allow the quick release of air, followed by chest tube placement.

Contraindications

To date, chest tube placement has no absolute contraindications in the neonate population. However, relative contraindications include the presence of diaphragmatic hernias or systemic anti-coagulation, particularly in patients receiving extracorporeal membrane oxygenation. In this anticoagulated population, chest tube placement may yield significant adverse effects, including major bleeding complications and death.[8] Special precautions should be undertaken for neonatal patients following cardiac or thoracic surgery, given the pediatric population's unique anatomy.

Equipment

The clinician should become familiar with supplies included in chest tube kits at their institution, as instruments included in these kits vary. Provider preferences may also influence equipment availability. Items necessary before starting the procedure include:

• Chest tube: 10F to 12F for infants weighing greater than 1500 grams; 8F to 10F for infants weighing less than 1500 grams
• Atrium, sealed, or Pleur-evac® drainage system [16]
• Sterile procedure attire, including gowns, gloves, and hats
• Sterile prep and drapes to ensure a sterile field
• Scalpel for skin incision, either a 15-blade or 11-blade
• Clamp for blunt dissection and pleural entry, either a curved Kelly clamp or mosquito hemostat
• 4-0 (or 3-0) silk suture on cutting needle
• Occlusive dressing (Tegaderm, xeroform, 4 x 4 gauze)

Personnel

Only authorized individuals properly trained in placing a chest tube should perform the procedure. An assigned assistant may be present to aid the provider performing the chest tube placement. However, only 1 individual is necessary. Depending on the patient's size and age, sedation and analgesia most likely will need to be provided by another physician to ensure limited movement and patient discomfort during the procedure. For neonates and children, the presence of another physician or specialist may be required to ensure that the airway is secure and the patient’s vital signs are properly monitored during chest tube placement. In most small neonates and infants, general anesthesia with endotracheal intubation may be preferred. Support staff may also be in the room to help monitor the patient, administer medications, provide supplies, and report vitals during the procedure.

Preparation

All available preprocedure imaging should be carefully reviewed, including chest ultrasound, x-ray, computed tomography, and magnetic resonance imaging. While preparing for chest tube placement, sedation and analgesia can be administered intravenously to provide patient comfort. However, extreme caution should be exercised before chest tube placement. The patient's vital signs should be carefully monitored to ensure no further clinical compromise occurs, especially if the patient is already exhibiting symptoms from the pleural fluid or air. Additionally, a local anesthetic may be injected to further minimize procedural discomfort, though recognition of the toxic limits of the local agent should first be calculated.[17] Administering local anesthetic agents directly under the skin by creating a wheal and in the projected track of the deeper dissection down to the rib can provide additional pain relief.[7]

Sterile tools must be obtained by the healthcare provider and assistants, including sterile towels, gloves, hats, masks, gowns, and equipment. The area of the intended incision will require adequate skin cleansing using surgical antimicrobial skin swabs (eg, Betadine or chlorhexidine).

The patient should be closely monitored at all times with frequent vital checks, including pulse oximetry and blood pressure. Dedicated support staff should be assigned to ensure that all equipment has been checked for functionality and that backup equipment is nearby in case of malfunction.

Before the procedure starts, the healthcare provider should perform a final time-out, identifying the correct patient and the pathology's laterality. However, a time-out may not always be performed if the chest tube is emergently indicated.

Technique or Treatment

Chest Tube

Chest tube placement in the neonate can be used to treat various conditions. The appropriately sized chest tube is used on the affected side. Like adults, the 4th or 5th intercostal space in the anterior midaxillary line is the primary landmark for the chest tube insertion site. Note that the risk of hitting the liver or spleen increases if the chest tube is placed more inferiorly. Meanwhile, a more anteriorly placed chest tube poses a higher risk of injuring the thymus, great vessels, or the heart. The chest tube is angled posteroinferiorly for fluid collections and anterosuperiorly in the chest cavity for pneumothoraces.[18]

An incision is made overlying the skin at the 4th or 5th intercostal space in the anterior midaxillary line. Using a Kelly or mosquito clamp, blunt dissection is performed directly above the rib through the subcutaneous tissue, avoiding injury to the intercostal neurovascular bundle below the superior rib. Careful, steady pressure is applied to dissect the pleura bluntly. Bracing the clamp with 2 hands while performing this step may help prevent uncontrolled damage to the mediastinal organs.

Once inside, the clamp is opened widely to create an entry tract for the chest tube. A rush of air or blood should be noted at this point, depending on the pathology requiring the thoracostostomy. The clamp must be retracted with the prongs open to widen the tract. A finger is inserted inside the tract to sweep the inside of the thoracic cavity and feel for the lung to confirm entry above the abdominal cavity. The chest tube is guided into the thoracic cavity using the Kelly or mosquito clamp. The last hole on the chest tube should be completely within the thorax. Depending on the length, the chest tube may need to be trimmed to ensure the most distal hole is within the chest cavity, especially in small children.

Once the chest tube has been properly positioned, it must be secured to the skin according to institutional guidelines, usually with a nonabsorbable suture (eg, silk or nylon). At this point, the chest tube should be connected to the drainage system and wall suction. The indicator on the drainage container should demonstrate that the suction is working properly and set from -10 to -20 mm Hg, depending on physician preference. The quality and quantity of the evacuated liquid or air must be monitored. Reexpansion pulmonary edema may occur if large amounts of pleural fluid are drained too quickly in older children or adults with chronic large-volume effusion, although this condition is rare in babies. A chest x-ray must be immediately obtained to radiographically confirm that the chest tube is correctly placed.

Pigtail Catheter

Inserting a pigtail catheter using the Seldinger technique is another common method to treat a pneumothorax or simple pleural effusion. Healthcare providers should familiarize themselves with their institutions' pigtail catheter kits before placement since kit elements may vary. After confirming sterility and injecting local anesthesia, an 18-gauge needle with an attached syringe is inserted into the patient's skin at the 4th or 5th anterior midaxillary landmark while aspirating to verify placement. For pleural effusion, fluid from the syringe may be sent for studies at this time.

After removing the syringe, the J-tip of the guide wire is slowly inserted via the needle into the chest cavity. The needle is withdrawn while holding the guide wire in place. The dilator is placed over the guide wire to dilate the skin and subcutaneous tissue. The dilator is then gently advanced over the wire, which is kept firmly in place. The dilator is subsequently removed over the guidewire. The pigtail catheter is afterward advanced over the guide wire until all holes on the pigtail are within the chest. The guidewire is then withdrawn while holding the pigtail in place. Doing so curls the pigtail against the chest wall. The pigtail is sutured to the skin with a nonabsorbable stitch and connected to its atrium or Pleur-evac®. A chest x-ray must be immediately obtained to confirm that the pigtail is correctly placed in the chest cavity.[3]

Postinsertion Dressing Care

Following insertion and suturing to the chest wall, the chest tube should be covered with a nonocclusive dressing according to institutional guidelines. The insertion site must first be covered with Xeroform, followed by gauze and Tegaderm, to create an occlusive dressing. The dressing should remain in place until the chest tube can be removed. An exception to this rule is if the dressing becomes saturated. If warranted, only qualified personnel should change the dressing according to the previously described sequence.

Postprocedure Infection Control

Postprocedure antibiotics are generally not indicated following a chest tube insertion, but their use should be discussed with the attending physician. Infection may be introduced into the chest cavity if the sterile technique is not observed during insertion. Dressing changes at the chest tube insertion site must be limited to minimize the introduction of infection.

Collection System Management

Following chest tube insertion, approximately 45 cc of sterile water is added into the atrium via the port located on top of the drain until it reaches the 2 cm fill line. The chest drain is then connected to the patient before initiating suctioning if indicated. Afterward, the suction line is connected to the port on the top of the chest drain atrium. The atrium should be kept in an upright position, with the tubing placed below the level of insertion in the chest cavity. The suction regulator is preset to -20 cm. The indicator on the drainage container should demonstrate that the suction is working properly and set from -10 to -20 mm Hg, depending on physician preference. The chest tube and drainage system must not be stripped. The quality of the output from the chest tube must be checked, with the drainage in the atrium recorded as instructed, no less than every 8 hours per day.

Termination of Chest Tube Treatment

The chest tube should be removed if occluded or no longer needed once clinical or radiographic evidence of improvement is obtained. Before chest tube removal, a clamping trial may be indicated to test how the patient responds without the chest tube in place. Following a discussion with the attending physician, a chest tube clamping trial may be performed by placing a Kelly clamp across the tubing that connects the chest tube to the atrium device. The vital signs should be monitored carefully during a clamping trial. A low threshold for removing the Kelly clamp should be used during a clamping trial, ensuring that the patient does not desaturate or exhibit worsening chest pain during this time. At the end of the clamping trial, a chest x-ray image should be obtained to evaluate for worsening pneumothorax or effusion. If the clamping trial is successful, a discussion should be held to determine the timing of chest tube removal. Reaccumulation of pneumothorax or effusion may warrant a longer duration of chest tube therapy.

Removing a neonate's chest tube requires careful observation of patient respirations. The process is initiated by removing the chest tube dressing and taking the chest tube atrium off-suction. Scissors may be used to remove the suture securing the chest tube to the skin surface. The chest tube must be free from all attachments to the patient. The patients’ respirations must be observed, noting the timing of peak inspiration or expiration on the monitor.

The chest tube must be quickly pulled out of the chest cavity once the patient has reached a moment of peak inspiration to prevent pneumothorax. Immediately following chest tube removal, another occlusive dressing is placed on the site using Xeroform, 4 x 4 gauze, and Tegaderm. This dressing must be completely secured and occlusive. Otherwise, air may leak into the wound, accumulate, and cause a tension pneumothorax. Following chest tube removal, institution guidelines must be reviewed to determine if a postremoval chest x-ray is indicated to assess for pneumothorax development.

Complications

Chest tube insertion in any patient risks injuring intrathoracic and intraabdominal organs. In particular, a left-sided chest tube in the neonate population carries a high risk of penetrating the pericardium, given these patients' thin chest walls.[19] No differences in mortality have been reported when comparing needle aspiration versus chest tube drainage to manage neonatal pneumothorax.[14] Other potential complications include perforation of the lung, diaphragm, or mediastinum.[20] Importantly, complications may not be readily apparent, as clinical findings are often nonspecific despite thoracic or abdominal organ injury.[21] In addition, chest tubes occupying the right superior pleural space and in contact with the phrenic nerve have a higher risk of diaphragm paralysis.[22]

Following chest tube insertion, care must be taken to ensure proper tube output management and observation. Removal of a chest tube prematurely may result in reaccumulation of pleural effusions and may even necessitate reinsertion of a chest tube, thereby increasing hospital length of stay.[23] In addition, the development of a clinically significant pneumothorax after chest tube removal may not always change the patient's clinical status following cardiac surgery, making it imperative to observe this particular patient population closely.[24] 

If the chest tube becomes dislodged or disconnected, the primary team caring for the patient should be immediately contacted. The vital signs should be carefully monitored. If time allows, the chest tube must be cleaned with an alcohol wipe before reconnecting to the drainage system. However, if the patient is acutely decompensating and supplies are not immediately available, the chest tube should be connected to the drainage system, and the attending physician should be notified of the incident. A chest x-ray should be obtained to monitor the patient's condition.

Clinical Significance

Space-occupying thoracic diseases may be life-threatening or cause significant morbidity to the neonatal patient. Untreated, tension physiology may develop, ultimately leading to cardiopulmonary arrest. Understanding the steps in performing a neonatal thoracostomy and recognizing this group's unique thoracic anatomy may help clinicians better treat diseases of the neonatal pleural space.

Enhancing Healthcare Team Outcomes

An interprofessional approach to chest tube placement in neonates may help improve outcomes while limiting complications. Open communication within the interprofessional team while preparing for the procedure can improve the efficiency and timeliness of thoracostomy placement. Coordination between team members in monitoring oxygenation and vital signs before, during, and after chest tube placement is paramount to optimize patient safety.

Nursing, Allied Health, and Interprofessional Team Interventions

Nursing care is key during the initial placement and postinsertion monitoring of chest tubes. The nursing staff should ensure that the chest drain tubing is properly secured and attached to the suction apparatus if indicated. In addition, ongoing monitoring of the patient's chest tubing is crucial to minimize tubing tension or kinking. The nursing team's evaluation of a patient's condition may provide the first opportunity to identify a space-occupying lesion in the chest cavity that warrants a chest tube placement.

Nursing, Allied Health, and Interprofessional Team Monitoring

Nursing care is critical in monitoring patients with chest tubes. Depending on the indication, patients with chest tubes may be initially monitored in an intensive care unit, step-down unit, or ward. Oxygen saturation levels should be closely followed to determine the effectiveness of the chest tube. In addition, drain output amount and quality should be recorded no less than every 8 hours. The quantity of output will be useful in determining the necessity of further surgical intervention.