Bougie-Guided Chest Tube

You’ve got to love the twitter! Seth Trueger (@mdaware) tweeted that his EM Attending brother-in-law, Charles Maddow, has started using bougies to guide in thoracostomy tubes on morbidly obese patients with thick soft tissue around the entry site. I worried whether the bougie is long enough to allow a sig. portion to be placed in the chest cavity but still allow seldinger maneuver.

My amazing friends from (@HQMedEd) sent this photo:

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Then Graham Walker (@grahamwalker) pulled this shot from his sim lab:

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Minh (@rfdsdoc) mentioned this article where they used a similar technique with ET tubes instead of chest tubes, originally posted on Cliff’s (@cliffreid) blog.

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Comments

  1. I’ve tried this before. I’m not a fan.

    In setting of non traumatic, stable patient with pneumothorax that needs a tube, I think a pigtail is the best option and it’s easily placed no matter how obese. Avoids a lot of morbidity of bigger tube.

    For patients with history of prior hemo or pneumothorax, significant copd, cancer in the lungs/thorax. or basically any patient at risk for thoracic adhesions, I think this method makes iatrogenic injury to the lung more likely because you can’t sweep adhesions aside or assess the situation before putting the tube in.

    In very obese patients, if you were to use this method I think you need to be very careful you aren’t creating a false passage which is easier than you may think sometimes and your tube ends up subcutaneously placed!

    Dont get me wrong I love boogies… I just think for surgically inserted devices, there is no substitute for an experienced tactile sensation you can only get with your finger. (same with crics…. Cut down, feel opening in trachea FIRST and only after this guide a boogie while feeling to help with placement of tube)

    It’s a nice idea and certainly has a role. Sometimes you are in the chest with your finger and it’s just very hard to get the tube in for whatever reason over your fiber, with clamp, etc…. Guiding boogie with guide of your finger to assure its where u want it and in general trajectory you want it and then putting tube in this way may be nice alternative than making incision bigger.

    • My impression and the only way I would use this technique is AFTER putting the finger in and 360 sweep. Bougie would only be as a guide for the chest tube after feeling the bougie enter the cavity under your finger if I am understand what was relayed to me correctly.

      • If the finger goes in first, then that’s great! As long as your are darn sure your boogie is actually going into the thoracic cavity into a trajectory you like after you have assessed the situation with your finger.

        Regarding the length of a boogie though, in an obese patient it wouldn’t be long enough potentially… and you don’t want to lose your boogie in the patient! One could use an ET tube exchanger which is significantly longer though.

  2. minh le cong says:

    to be honest, I am not convinced this adds much. In the surgical airway, you can get away with it because the anatomical distances are not so great. In the chest wall, if you are having problems, its better to make a bigger incision and dilate it with your finger. Also the Gordon Ewing case always makes me respect the potential for a blind passage of a plastic semi rigid thin tube to penetrate the lung, albeit it was spurting 15L per min of oxygen at the tip.

  3. “crack of the scrotum popping”. How awful.

    Agree – too much chance of a false passage I reckon. Unless it’s finger-bougie-chest tube…

    On an aside, I have fiddled with the bougie-ETT tube alternative to formal chest tube in an animal lab with sheep…fairly robust, but I do wonder how comfortable it is for the patient.

  4. Meanwhile, those Norse Gods of anaesthesia/ICU suggest that a central line may be appropriate for some PTXs

    http://www.scancrit.com/2012/04/27/2937/

  5. Andrew Bowman says:

    I prefer the Thal Quik chest tubes.

  6. Chloella says:

    Interesting.

    If you watch thoracic surgeons put chest drains in they use the trocar, in a similar way to how we would use the needle in an IV cannula – insert just into the cavity but no further, point towards the apex and slide the drain over and in. It looks very slick, and it works well PROVIDED you have already made a track for it and are not using the trocar to make the hole. I have never found the technique of guiding the drain towards the apex using forceps very satisfactory, it just makes the hole enormous and worsens surgical emphysema.

    However we have now been supplied with drain tubes without trocars as so many people seemed to be under the impression that chest drains are placed by making a small nick in the skin, arming yourself with the drain over a trocar and taking a massive run up stopping only when you’ve transected the heart, both lungs, the opposite chest wall and a nurse who couldn’t move out of the way quick enough.

    So the bougie may be a very useful addition to the arnamentarium.

    By the way I HATE pigtail drains and they are not as safe as they are cracked up to by. Done properly a drain placed by blunt dissection is very safe if less comfortable.

  7. Jesse says:

    How do you get a sterile bougie?

  8. DocXology says:

    I was convinced to switch to the method that Chloella mentions by a CT surgeon during a trauma for all the reasons given. Incise-blunt dissect-release air/blood – finger sweep – trocar tip alongside – take finger out – advance tube. Elegant, safe, quick, small cut, no subcut emphysema. I

    • Trocars have long been removed from chest tubes in the States. They are rife with complications. If you folks are using them just as a guide ask yourself why they are extremely sharp. If they were intended to be used in the way you describe, they would have a beautifully rounded tip and there would be no problem with their use. Try the bougie instead, much safer guide.

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