Pigtail Catheter Placement for Pneumothorax

Traditionally, a pneumothorax has been treated with a large bore chest tube connected to suction, with inpatient observation until the chest tube can be pulled.   The patient, if stable, would then be discharged home.  Persistent discomfort, infection, and other complication rates are not insignificant.

More recently, there has been a push to treat stable small pneumothoraces with less invasive methods such as observation or small bore chest tubes. In cases of unstable patients or those with hemopneumothoraces, a large bore chest tube continues to be the most appropriate treatment.

Pigtail Catheter Indications

  • Drainage of air or thin simple fluid
  • Current teaching is for PTX usage only if <40%
  • How to know if fluid is simple? Lateral decub XR to see if fluid layers out onto the side

 

Hunting and Gathering

Find a workstation on wheels (WOW) with a functioning Topaz to obtain informed consent

Supplies

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  • Pigtail Catheter kits are currently not kept in clean utility rooms or in the critical care rooms. You will need to CALL SUPPLY and have them bring you a kit.
  • Extra 1% lidocaine
  • Sterile Gloves
  • Sterile Gown
  • Hat
  • Mask with eye shield
  • Sterile flush or 10cc of sterile saline

Setup

  • Patient Position: supine with arm above head, same as for a thoracostomy tube. Consider soft restraints to help the patient keep the arm in position.
  • Draw up your lidocaine into the provided syringe
  • Place the dilator all the way into the pigtail catheter
  • Prep the guidewire into the red applicator
  • Load the finder needle syringe with 3-4cc of sterile saline. Or take the sterile flush and discard 6-7cc of saline. Connect to the finder needle

The Procedure

1) identify the 4th or 5th intercostal space — same space as for traditional chest tube

2) Sterilize and drape.

3) Anesthetize the skin and deeper tissues down to the superior aspect of the inferior rib in your chosen intercostal space. Draw back before injecting to ensure you are not in a vessel. Anesthetize to the parietal pleura. This is identified by advancing the needle over the rib little by little while drawing back after each advancement. When bubbles are drawn back into the syringe, you have gone through the parietal pleura. Pull back slightly and inject a generous amount of lidocaine, as the pleura is particularly sensitive.

4) Take your finder needle and insert the needle over the superior aspect of the rib while drawing back. Once in the pleural space, the syringe plunger will give way, aspirating bubbles in pneumothorax and pleural fluid in effusions.

5) Remove the syringe from the needle and pass the guide wire in just enough to clear the needle. Try to point your needle postero-superior, as this the direction you want your catheter to travel. Most of the guide wire should be hanging out. If inserted too far it will be difficult to direct the pigtail catheter superiorly into the apex of the thorax.

6) Make an incision with scalpel adjacent to the needle and continuous with the hole made by the needle. Making the incision prior to removing the needle (not done this way in video) is helpful, as the needle is larger than the wire and thus ensures your incision is continuous with hole.

7) Remove the needle leaving the wire in place. As with any seldinger procedure, always have one hand holding the needle. Then, pass the dilator over the wire and into the pleural space. You should feel the dilator “ give way” once you are in.  Check that the guide wire is moving freely in and out of the dilator throughout this process to avoid kinking the wire.

8) Pass the pigtail with its trocar over the wire. It is best to pass it all the way to the third guideline. If it ends up being too deep, you can always pull back.

9) Remove the trocar and guidewire in one pull.

10) Connect the catheter to the connecting tube which will then attach to the chest tube pleuravac.

11) Suture the catheter to the skin in the same fashion as you would for a chest tube and cover with an occlusive dressing such as xeroform and a sterile tegaderm.

12) Obtain an XRay to confirm placement.

3 thoughts on “Pigtail Catheter Placement for Pneumothorax

  1. Your post got some nice praise and a shout-out from our Critical Care/Pulmonary guest speaker at EM conference today! He also made the point that if you use bedside ultrasound to clearly identify your diaphragm, and go at least one rib space up from there, you don’t necessarily have to stick to the ‘triangle of safety’–you can go where the fluid is.
    Nice job, Jay!

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