Chest Tube Placement and Management

Wound Care

Incision care is usually routine if the skin is closed. Open wounds historically are packed with gauze moistened with saline, dilute antibiotic solution, sodium hypochlorite (Dakin's) solution, acetic acid solution, or dilute Betadine solution. Newer dressings, including silicone-impregnated dressings, thin polyurethane films, hydrocolloids, alginates, polyurethane foams, and hydrogels, are available, although there are no strong data to recommend the use of one over the other or gauze. Vacuum dressings can be placed in clean wounds and can speed the healing process. Open chests for bronchopleural fistula are packed with gauze soaked in antibiotic solution until a decision is made about definitive closure. If muscle or skin flaps are raised and there is the potential for seroma formation, drains may be left and binders or ace bandages can be considered. Depending on the muscle rotation used and the tautness of the closure, restriction of range of motion may be required for several days to prevent tension and dislodgement or compromise of flap vascular supply.

When tracheal resection with primary anastomosis with release procedures are done, a sturdy skin stitch from the chin to the anterior chest will remind the patient to keep the head neutral or mildly flexed to allow healing of the tracheal anastomosis with less tension. For wounds that are difficult to heal, such as those in previous radiation fields, hyperbaric oxygen therapy can be considered. A minimal oxygen concentration must be achieved for any benefit of this cumbersome and costly wound care alternative. No randomized, blinded studies have shown definite benefit of hyperbaric oxygen therapy for wound healing except for osteoradionecrosis.

Management of Drainage Tubes

Placement and removal of chest tubes should be standardized by protocol after lung resection. Tubes are left in as long as any air leak remains, but recent studies indicate that earlier transition from water suction to water seal is not harmful and promotes quicker resolution of parenchymal air leakage. Fluid drainage of 300 to 400 mL or less per 24 hours is acceptable for chest tube removal after lung resection. Chest tube removal after pleurodesis for malignant pleural effusion has a stricter volume requirement, as these patients are known to have problems absorbing pleural fluid normally. Chest tube removal after drainage of chylothorax or empyema must be tailored to the particular patient's course. When there is any concern about anastomotic leak in the chest or mediastinum after esophageal resection or tracheal reconstruction, tubes should be left until resolution of the leakage. Mediastinal tubes are left after median sternotomy is performed for removal of bilateral lung tumors, lung reduction surgery, or mediastinal mass resection.

A nasogastric tube is left after esophagectomy and for complicated benign esophageal operations. The tube is removed when drainage from the gastrointestinal tract is less that 300 to 500 mL/24 hr and there is no concern of anastomotic leak.

Bladder catheters are placed for drainage and as a measure of adequate end-organ perfusion in patients having operations longer than 3 hours. Patients, especially older men, who have an epidural catheter often have difficulty voiding and usually require the indwelling bladder catheter until the epidural is discontinued.

Physical Therapy

Exercise therapy after lung resection benefits patients by decreasing pulmonary complications, restoring mobility and independence, and decreasing the potential for deep venous thrombosis. Pulmonary rehabilitation is designed specifically to help patients clear secretions, strengthen respiratory muscles, and provide cardiopulmonary exercise. A patient who requires continuous chest tube suction can exercise on a stationary bicycle in the hospital room.

Management of Complications