Browse the corpus

Chest tube placement, or thoracostomy, is a critical procedure performed to drain air, fluid, or pus from the pleural space. Chest tubes and pigtail catheters have become increasingly important in treating pediatric pleural space diseases. Chest tube indications in the neonate are similar to those in adults. However, the anatomical differences between these populations make neonatal thoracostomy tube placement challenging to the untrained provider. Successful performance of this procedure involves careful preparation, precise execution, and vigilant postprocedure monitoring to ensure optimal outcomes for these vulnerable patients. This activity for healthcare professionals is designed to enhance learners' competence in identifying and managing neonatal conditions requiring chest tube placement. Participants gain a deeper understanding of neonates' unique anatomy that can make chest tube placement and care difficult. Participants hone their skills in recognizing the procedure's contraindications and addressing potential complications. Improved proficiency equips learners to collaborate effectively within an interprofessional team caring for neonates requiring a thoracostomy. Objectives: Identify the signs and symptoms indicating that a neonate has chest tube placement indications. Implement proper techniques when performing chest tube placement in the neonate. Identify chest tube placement complications. Collaborate with other healthcare professionals to enhance health outcomes by providing efficient, comprehensive, and coordinated care to neonates requiring a thoracostomy and postprocedure care. Access free multiple choice questions on this topic.

Thoracostomy (chest) tube placement in pediatric patients is often used for post-congenital cardiac surgery respiratory support, emergent airway management, and pleural space disease treatment. Although pigtail and venous catheters are increasingly used, the chest tube is the mainstay of therapy for pneumothoraces.[1] Placement and care of pediatric thoracostomy tubes may present specific challenges compared to the adult population due to unique thoracic anatomic and physiological differences.[2] Understanding the neonate's unique anatomy and physiology is crucial for proper chest tube placement and management, minimizing 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.

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 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 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.