Ann Thorac Surg 2006;82:1543-1544
© 2006 The Society of Thoracic Surgeons
How To Do It
Modified Central Line for Pneumothorax
M. Blair Marshall, MD*
Division of Thoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and Division of Thoracic Surgery, Georgetown University Medical Center, Washington, DC
Accepted for publication October 31, 2005.
* Address correspondence to Dr Blair Marshall, Division of Thoracic Surgery, Georgetown University Medical Center, 4 PHC, 3800 Reservoir Rd, Washington, DC 20007 (Email: mbm5{at}gunet.georgetown.edu).
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Abstract
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Pneumothoraxes, whether spontaneous or iatrogenic, frequently require drainage. Although the recent trend has been toward a catheter-based approach, many thoracic surgeons continue to use chest tubes. Tube thoracostomy is associated with significant pain at the time of insertion and during continued drainage. Pneumothorax catheters are less painful but more expensive, and some have been associated with significant failure. After disappointing experience with pneumothorax catheters, we have modified a central line to use in lieu of a pneumothorax kit. We have found this technique to be effective, safe, reliable, and inexpensive.
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Introduction
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Since the first description of the management of pneumothoraxes with small bore catheters, many have adopted this approach [1]. A variety of pneumothorax catheters and insertion kits are available today, and many have described adaptation of catheters for use in the pleural space [1–4]. These catheters have the advantage of being smaller and less painful than most chest tubes and thus do not require intravenous sedation or analgesia for their insertion. However they do not always work as effectively as chest tubes and higher recurrence rates, catheter occlusion, and dislodgement have been reported [1]. We have found this to be true in our own experience.
During a 3-year period, we used the Arrow pneumothorax catheter kit (No. AK-01500) (Arrow Intl, Reading, PA). For this particular catheter-based kit, the technique for insertion is an 8-French catheter over an 18-gauge needle. The catheter itself is blunt and as the insertion technique is not Seldinger, thus there is no pre-dilated tract. This leads to a fairly blunt insertion, which is difficult and can be painful. In addition, the inherent properties of the catheter itself, being made of a thin-walled stiff plastic, allow it to easily occlude once placed into the soft tissues and the needle is removed. The drainage ports are few and small. The catheter occludes frequently, necessitating replacement of another catheter or placement of a chest tube. Attempting to find the optimal catheter, we tried other small bore catheters, but we were continually disappointed for several reasons (ie, the catheters did not come with all of the instruments or preparation and drapes to facilitate the procedure; they were not Seldinger based; they easily occluded or were expensive). With this experience, we sought for another more optimally suited catheter.
The single lumen central line kit (No. CK-04711) (Arrow Intl) is a 14-gauge single lumen central line catheter with an insertion kit. It is easily modified and adapted for use as a pleural drain (Figs 1A–1E). This catheter is very pliable and bends without occlusion (Fig 1F). These kits also have the additional advantages in that they are Seldinger based and are relatively less expensive than pneumothorax kits ($19.80 vs $77.00 per kit). However, for the central line catheters, there are few drainage holes and their Leur-Lock attachment does not fit into a standard drainage system or Heimlich valve. This led us to modify this catheter by placing multiple drainage holes to use as the pneumothorax catheter and obtaining an adaptor to optimize the connection.
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Fig 1. (A) Catheter and needle used to enter pleural space and to place guide wire. (B) 14-gauge single lumen central line. (C) Leur-Lock connector (Atrium Medical Corp, Hudson, NH) with attached tubing adaptor. (D) Sterile suture scissors for cutting extra drainage holes. (E) The single lumen catheter following placement of several additional drainage holes. (F) Image demonstrating ease of occlusion for stiff catheters compared with the central line.
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Technique
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The 14-gauge single lumen central venous catheter kit (No. CK-04711) (Arrow Intl) was used at a cost of $19.80 each. The sterile suture removal kit (No. 66100) (Tyco/Healthcare, Mansfield, MA) was used at a cost of 51¢ each. The Leur-Lock connector (No. 19927) (Atrium Medical Corp, Hudson, NH) was also used at a cost of $3.00 each.
Informed consent was obtained from all patients prior to placing the catheter. Once the patient was placed in the supine position and prepped, we used the anterior axillary line, third or fourth intercostal space in most patients. In obese patients, we have found the second intercostal space in the mid clavicular line to be the easiest. Prior to placing the catheter, extra holes are cut taking care not to compromise its integrity. The skin and subcutaneous tissue are anesthetized with lidocaine. The 18-gauge catheter over the 20-gauge needle is chosen to enter the pleural space (Fig 1B). Additional lidocaine is used to numb the pleura and pleural space after the needle aspirates air. It is important to note that we use the insertion catheter over the introducer needle to access the pleural space, as once air is aspirated, the remainder of the procedure can be performed through the blunt tipped catheter instead of the needle, thus limiting risk of parenchymal injury. The catheter slides over the needle into the pleural space and the needle is removed. The opening is obstructed to prevent air from entering the chest. The guide wire is inserted into the pleural space, and the catheter is removed. A nick is made in the skin, and the dilator is used to dilate the tract, as with the standard Seldinger technique. One should be careful not to let air enter the pleural space while exchanging catheters and dilators. Finally, the single lumen catheter is threaded over the wire and secured in place. The special connector allows one to easily and securely connect the catheter end (ie, the Leur-Lock connector [Atrium Medical Corp]), to the larger "football" connector that comes attached to the standard drainage system. In addition, as this connector is Leur-Lock (Atrium Medical Corp) based on one end with a flexible segment of tubing at the other end (Fig 1D), a Heimlich valve may be directly attached as well.
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Comment
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During the past 2 years, we have used this technique to treat 17 patients with 18 pneumothoraces (ie, 9 iatrogenic: 7 post central line insertion and 2 after chest tube removals), and 8 spontaneous pneumothoraces. One patient with an initial spontaneous pneumothorax required replacement of a catheter for recurrent pneumothorax after catheter removal.
Our experience with this technique is markedly improved from previous experience with other small bore catheters as well as chest tubes. Placement is essentially painless after local analgesic and no intravenous sedation or analgesic is required. In addition, patients report minimal pain while the catheter is in-dwelling, in contrast to a standard chest tube. With this current technique, we have not had any failures related specifically to the catheter; it has functioned effectively to drain both pneumothoraxes and effusions, particularly in patients with iatrogenic pneumothoraces who may have pleural effusions related to underlying co-morbid disease. With everything required to place this catheter, central line kit, suture scissors, and Leur-Lock connector (Atrium Medical Corp), the cost remains significantly less than a pneumothorax kit. Also, because there is a significant failure rate with some pneumothorax catheters, the potential cost savings is greater, as patients do not require repeat procedures for catheter failure. Although it may not be necessary to cut extra drainage holes in these catheters, as the standard pneumothorax catheters had few holes and a high failure rate in our experience, the additional holes may have contributed to the low failure rate observed with this technique. We also believe that the inherent difference in plasticity with this catheter prevents the frequent occlusion observed with other catheters.
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References
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- Grodzin CJ, Balk RA. Indwelling small pleural catheter needle thoracentesis in the management of large pleural effusions Chest 1999;111:981-988.
- Chetty GV, Elahi MM, Siddagangaiah V, Leverment J. Bonanno's catheter: a less invasive and cost-effective alternative for drainage of pleural effusion J Thorac Cardiovasc Surg 2005;129:219-220.[Free Full Text]
- Singh K, Loo S, Bellomo. Pleural drainage using central venous cathters Crit Care 2003:R191-R193.
- Vedam H, Barnes DJ. Comparison of large and small-bore intercostals catheters in the management of spontaneous pneumothorax Int Med J 2003;33:495-499.
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Abstract
Introduction
