Intercostal catheters can kink, obstruct, or get pulled out. These hazards are greater during transport of the patient. Critical care and retrieval medicine doctors in Queensland, Australia (where many people are having a bad time right now) have invented an elegant alternative: using a cuffed tracheal tube in the pleural space instead. It can be attached to a Heimlich valve.
They even used a bit of science to demonstrate its effectiveness, by creating pneumothoraces and haemothoraces in sheep and comparing the tracheal tube with a standard intercostal catheter (ICC).
The method for insertion is simple:
- Breach the pleura
- Insert a 14 Fr Cook intubating bougie into the thoracic cavity
- Railroad a 7.0 mm internal diameter tracheal tube (ETT) into the chest cavity
- Inflate the cuff
- Retract the tube until resistance is felt.
- Remove the ETT connector
- Attach a Heimlich valve
The results of the comparison are convincing: ‘The ETT proved faster to insert for both sheep. This was likely because it did not require suturing. Both the ETT and the ICC were comparable in draining blood. It was noted that neither tube was particularly effective when the haemothorax was positioned ‘side-up’. When turned ‘side-down’, both tubes successfully drained blood. Despite having multiple drainage ports, the ICC required more manipulation and was noted to kink. Conversely, the ETT with a single lumen and a Murphy eye, was stiffer and drained a similar amount of blood without the catheter having to be milked.’
Proposed advantages of this method include:
- More portable equipment
- Faster insertion
- Provides kit redundancy
- Does not require suturing
- Avoids operator trauma from any sharp edges such as a fractured rib. (No attempt was made to place a finger into the chest cavity in the ETT group).
- Allows for a smaller incision
- Less trauma to the insertion site
- Might also offer a back up, when conventional equipment has been exhausted.
The authors graciously note that both Portex and Cook have developed ICC kits that now go some way in supporting the original idea behind this study. These include flexible introducers (Portex) and guidewire insertion technique (Cook).
Appraisal of the endotracheal tube as an alternative to the intercostal catheter
Emerg Med Australas. 2010 Dec;22(6):573-4