Chest tube insertion





Definition

A chest tube insertion is a procedure to place a flexible, hollow drainage tube into the chest in order to remove an abnormal collection of air or fluid from the pleural space (located between the inner and outer lining of the lung).


Purpose

Chest tube insertions are usually performed as an emergency procedure. Chest tubes are used to treat conditions that can cause the lung to collapse, which occurs because blood or air in the pleural space can hamper the ability of a patient to breath.

There are four common conditions than can require surgical chest tube insertion, including:

  • pneumothorax (air leak from the lung into the chest)
  • hemothorax (bleeding into the chest)
  • empyema (lung abscess or pus in the chest)
  • pneumothorax or hemothorax after surgery or from trauma to the chest

Demographics

There is no available data concerning the demographics of chest tube insertion since this is a common procedure performed in emergency rooms and surgical departments. However, pneumothorax seems to occur most often in males 25–40 years of age.


Description

The point of insertion in the chest most commonly occurs on the side (lateral thorax), at a line drawn from the armpit (anterior axillary line) to the side (lateral) of the nipple in males, or to the side (about 2 in [5 cm]) above the sternoxiphoid junction (lower junction of the sternum, or chest bone) in females. The skin is sterilized with antiseptic solution covering a wide area, and local anesthesia is administered to minimize discomfort. At the rib chosen for insertion, the skin over the rib is anesthetized with lidocaine (a local chemical anesthetic agent) using a 10-cc syringe and 25-gauge needle. At the rib below the rib chosen for pleural insertion, the tissues, muscles, bone, and lining covering the lung are also anesthetized using a 22-gauge needle.

All health-care providers will take precautions to keep the procedure sterile, including the usage of sterile gown, facemask, and eye protection. All equipment must be sterile as well and universal precautions are followed for blood and body fluids. Chest tube size is selected depending on the problem; an 18–20 F(rench) catheter is used for pneumothorax, a 32–26 F catheter for hemothorax, and trauma patients usually require a 38–40 F catheter size; children generally require smaller tube sizes.

The patient's arm is placed over the head with a restraint on the affected side. For an insertion line down the armpit (axillary line insertion), the patient's head is elevated from the bed 30–60°. Using the anesthetic needle and syringe, the physician will insert a needle (aspirate) into the pleural cavity to check for the presence of air or fluid. Then, an incision is made and a clamp is used to open the pleural cavity. At this stage, either air or fluid will rush out when the pleural cavity is opened. The chest tube is positioned for insertion with a clamp and attached to the suction-drain system. A silk suture is used to hold the tube firmly in place. The area is wrapped and an x ray is taken to visualize the status of the tube placement.


Diagnosis/Preparation

The diagnosis for chest tube insertion depends on the primary cause of fluid or air in the pleural cavity. For malignancy (cancer)-causing pleural effusion (fluid in the pleural space filled with malignant cells), the diagnosis can be established with positive cytopathology (cancer cell visualization and analysis) and a chest x ray that shows fluid accumulation.

The typical diagnostic signs and symptoms of empyema (lung infection) include fever, cough, and sputum discharge as well as the development of pleural effusion (causing chest pain and shortness of breath). This type of lung infection can progress to systemic disease with such signs as weakness, and loss of appetite (anorexia). Chest x rays can readily allow the clinician to view the pleural effusion and can also help to detect pneumothorax, since there is visual proof in the displacement of the tissues covering the lungs as a result of air in the pleural cavity. Additionally, during physical examinations, people with pnemothorax have diminished breath sounds, hyperesonance on percussion (a highly resonating sound when the physician taps gently on a patient's back), and diminished ability to expand the chest. Computed axial tomography (CAT) scans can be used to visualize and analyze complicated cases that may require chest tube insertion.


Aftercare

The chest tube typically remains secure and in place until imaging studies such as x rays show that air or fluid has been removed from the pleural cavity. This removal of air or fluid will allow the affected lung to fully re-expand, allowing for adequate or improved breathing. After chest tube insertion, the patient will stay in the hospital until the tube is removed. It is common to expect complete recovery from chest tube insertion and removal. During the stay, the medical and nursing staff will carefully and periodically monitor the chest tube for air leaks or if the patient is having breathing difficulties. Deep breathing and coughing after insertion can help with drainage and lung re-expansion.

Aftercare should also include chest tube removal and follow-up care. The patient is placed in the same position in which the tube was inserted. Using precautions to maintain a sterile field, the suture holding the tube in place is loosened and the chest is prepared for tying the insertion-point wound. The chest tube is then clamped to disconnect the suction system. At this point, the patient will be asked to hold his or her breath, and the clinician will remove the tube with a swift motion. After the suture is tied, dressing (gauze with antibiotic ointment) and tape is securely applied to close the wound. A chest x ray should be repeated soon after tube removal and, within 48 hours, a routine wound care clinic follow-up is advised to remove the dressing and to further assess the patient's medical status and condition.


Risks

Although chest tube insertion is a commonly used as a therapeutic measure, there are several complications that can develop, including:

  • bleeding from an injured intercostal artery (running from the aorta)
  • accidental injury to the heart, arteries, or lung resulting from the chest tube insertion
  • a local or generalized infection from the procedure
  • persistent or unexplained air leaks in the tube
  • the tube can be dislodged or inserted incorrectly
  • insertion of chest tube can cause open or tension pneumothorax

Normal results

Chest tube insertion is a commonly used procedure, and it is typical for patients to recover fully from insertion and removal. If no complications develop, the procedure can relieve air or fluid accumulation in the pleural cavity that caused breathing impairment. Breathing is usually improved, and follow-up within the immediate 48 hours after hospital discharge is advised so that the patient can be further assessed with x rays and in the wound care clinic.

Morbidity and mortality rates

Mortality and morbidity for chest tube insertion is not strongly associated with the procedure itself. The primary cause responsible for fluid or air accumulation in the pleural cavity is related to continued illness and outcome such as pleural effusions caused by cancer (malignant pleural effusions). Cancer, and not the insertion of a chest tube, determines a patient's sickness and outcome. Chest tube insertion may be problematic in persons affected with certain connective tissue diseases.


Alternatives

The diagnosis, indications, and procedure for chest tube insertion are specific and unambiguous. There is no other alternative to rapidly remove accumulation of fluid or air within the pleural cavity.


Resources

BOOKS

Pfenninger, John. Procedures for Primary Care Physicians, 1st Edition. St Louis: Mosby-Year Book, Inc., 1994.

Townsend, Courtney. Sabiston Textbook of Surgery, 16th Edition. St. Louis: W. B. Saunders Company, 2001.


ORGANIZATIONS

American Thoracic Society Homepage. http://www.thoracic.org .


Laith Farid Gulli, MD Nicole Mallory, MS, PA-C Alfredo Mori, MBBS

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?


The procedure is simple and widely utilized. Chest tube insertion is performed in a hospital, usually in the emergency department by an emergency room doctor, resident-in-training, or medical house officer. The medical and nursing team will monitor the patient at the hospital until the tube is removed.

QUESTIONS TO ASK THE DOCTOR


  • How is the procedure performed?
  • Why do I need this procedure?
  • Will I need to be sedated?
  • When will I be able to resume normal activities?
  • What aftercare is recommended?

User Contributions:

sanvicente
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Oct 14, 2007 @ 10:10 am
CordiallY,i need know,after care,after 48 hours...Is necesary thoracis roentgen before remove It?
Dr.MS
shazia
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Jan 8, 2008 @ 10:22 pm
i have read tis article . it is simple and easy to understand for the new learners.
patti
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Jan 23, 2008 @ 6:18 pm
I recently had a chest tube put in due to surgical error, but for a while now since it was removed, I have had dizzy spells, and walking up the stairs I am short of breath, and trouble sleeping I was trying to give it time to heal, but it doesn't seem to be getting better. Any suggestions?
Patricia Goodnight
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Jan 28, 2009 @ 5:17 pm
I have had a lung pleura drain for the last 15months due to cancer and fluid buildup. We have drained every day until last week. For four days now, I have bled through foam pad and gauze. It is not painful, just worrisome. What should I tell my oncologist and surgeon who implanted the drain for me? Should I worry?
Donna
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Aug 2, 2009 @ 3:15 pm
WHEN POSITIONING A PERSON WITH A CHEST TUBE IN PLACE DO YOU POSITION THEM ON THEIR GOOD LUNG OR BAD? (BAD LUNG IS THE ONE WITH THE CHEST TUBE INSERTION).
SAPPHIRE
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Oct 20, 2009 @ 2:02 am
THIS ARTICLE CAN BE EASILY UNDERSTOOD. I JUST WONDER,AS A NURSE,WHAT SHOULD YOU DO IF THE CHEST TUBE DISLODGES?...HOW ABOUT THE PATIENT ITSELF?
Nova
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Jan 16, 2010 @ 8:08 am
IF accidenetly the outer tip of the tube gets contaminated, is it essential to replace or do somethin else. Please help asap. Thanks
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Feb 9, 2010 @ 9:09 am
how much drainage is needed for a chest tube to be removed
Lisa
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Feb 15, 2010 @ 4:16 pm
I got pnemonia in both lungs in the middle of sept.i was on life support for 7 days total of 3 chest tubes inserted from sept-end oct..now i get short of breath headaches weak tired and feel like sleeping alot have some good days but then i start thinking back trying to figure out what happened? and i feel depressed...is this a side affect? or after affect?
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Feb 16, 2010 @ 1:13 pm
I have a question in regard condition after the removal of a chest tube. My brother was admitted on Valentine's day with a collapsed lung and a chest tube was inserted without problem. After a 2 day stay in the hospital, the tube was removed and he was discharged 4 hours after the removal and an additional X-ray. He is now home and experiences the release of air from the wound when he has to cough. Is it normal for a patient to experience this and/or should we contact his medical doctor? The wound still have the dressing in place from his discharge today, so I do not think any air is re-entering his chest cavity.

Thank you
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Feb 19, 2010 @ 9:09 am
On the 25th of january I had a chest drain, my right lung was completely full of blood due to fractured ribs. Three weeks on after care Ive received and many x-rays my lung is working again but x-rays still show blood in the lung. Ive been told if I get sort of breath again they may need to chest drain again. Do i equiry my own doctor about this. many thanks.
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May 20, 2010 @ 2:02 am
Hey what should a lpn do in the event the client he/she is caring for pulls out the chest tube.What would be the next step after immediately applying a sterile gauze over the site.Please help
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Aug 23, 2010 @ 2:14 pm
How long is it before the pain from chest drains stops. I am now 5 weeks after surgery for removal of a section of lung after being diagnosed with lung cancer ands till get tingling and stinging.
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Sep 20, 2010 @ 5:05 am
why the patient have to breath out when perform the removal of the chest tube ?
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Sep 22, 2010 @ 3:15 pm
I have chest pain following the removal of a chest tube for spontaneous pneumothorax. I am concerned there may have been side effects even though I have had a CT scan and chest xray following discharge from the hospital. What should I be concerned about?
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Oct 3, 2010 @ 9:21 pm
I have had a chest drain for removal of 2000mls of plural effusion which occured over a 5 week period following fractured ribs. It is now 4 weeks since discharge from hospital. I am still experiencing quite a bit of pain, is this normal and when can I expect to recover completely.
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Oct 9, 2010 @ 11:11 am
these facts r very knowledgeable and educative.very helpful
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Oct 24, 2010 @ 4:04 am
i want to know that why it is inserted between only 16 to 18 ribs ?
and also why pneumothorax occurs more in tall and thin peoples than others?
please send me its answer soon.
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Nov 9, 2010 @ 5:17 pm
ive been recently released from hospital after having spontaneous pneumothorax and ive been getting nausea, tired spells,just feeling completly "off". im wondering if this is normal and will pass after recovery or is it something more serious?... I am also wondering if spontaneous pneumothorax is a common sign of having marfans syndrome? a genetic disease. if you can please get back to me as soon as possible would be great.
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Dec 19, 2010 @ 6:06 am
THIS IS A BEAUTIFUL ARTICLE AND I'LL LIKE TO BE A PART OF IT.

When u have a patient with plenty fluid or gas (450ml ), becareful not to attempt draining it all at once. Also ensure that there's a very reliable and large drip line set for the patient to rush in fluid (into the veins) if the procedure is complicated. At most allow about 200ml of fluid to flow out gradually at once, clamp the draining tube and let out more fluid in about 30min to an hour.
Falure to observe this two precautions may result in a shocked or sometimes dead patient. I had a woman with over 3500ml in the right side of the chest yesterday. Though she was deadly breatless as a result of this, yet we had to balance between the benefits of respiratory relief and dangers of cardivascular collapse. She is happy on the ward now.
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Mar 19, 2011 @ 9:09 am
HOW LONG should the chesttube stayin if your the fluids from your left lung is fully drained?
Also the doctor already put powder to seal it up,during this should you be on any antiobiotics?
Also havbing the chesttube in place for some days can you get an infeetion from this tube in you with nothing draining out?
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May 21, 2011 @ 7:07 am
nice research, really im enjoy in your lovely subject of this research.
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Jun 13, 2011 @ 3:03 am
just had explority opp for shortness of breathe had chest drain removed stil in severe discumfort and shortness of breathe how long does this last and how quick can i get back to work
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Jul 9, 2011 @ 10:10 am
POLICY & PROCEDURE IN CHEST TUBE INSERTION, REMOVAL & ASSISTING- NEW UPDATE
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Aug 2, 2011 @ 12:12 pm
how many cest tubes are placed in patient after removal of a lung?
Blanca Robles
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Oct 17, 2011 @ 5:17 pm
My brother got shoot and one of his lungs get hurt, he is under chest tube treatment, can you tell me about how long can he be out of the hospital aproximatly, he is responding very well to the treatment and getting better.
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Oct 28, 2011 @ 2:14 pm
I had a pneumothorax four years ago. The surgery was done by the wrong type of Doctor. If this happens to you demand that they use a Doctor who specializes in this type of surgery. I have been fighting with my Doctor over pain medication from the get go and still we do not see eye to eye. My last resort after trying everything alse s a nerve block which involves an injection in my back. This has been a living hell and I woud not wish it on anyone. Had some luck with clonazapam. Becuase it keeps you calm it helps in controlling a bit of the pain but not much. There hasn't been enough research done on this hence the pain after the fact. Hard plastic tubes shoved into your body can never be a good approach. A sfoter type of tube would be a good start.
Whatever you do do not let your Doctor bully you around for pain medication. No one deserves to live in pain. It has wrecked four years of my life and I am still fighting to find a way to eradicate what I live with everyday. Stay positive.
Jessica
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Oct 28, 2011 @ 5:17 pm
This is an excellent article! Very well explained, simply stated, and easy to follow and understand. Thank for writing this!
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Nov 19, 2011 @ 11:11 am
How long after a chest drain is removed should a post-drain-removal chest x-ray be taken?
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Nov 20, 2011 @ 1:01 am
Dear sir, i face this problem as on 1/11/2011 and reson is fall down from height and my right side four rib were fracture and doctor condcut hemothorax and remove blood from my lung area but now when i perform prayer and walk with small speed i feel pain my question is i did not feel pain in my fracture area but i feel pain down side of cuting point which conduct for hemothorax purpose please i thing may be some blood will remain in that area if some blood will be there what wil be side effects of this one please inform me i will be very thankful to you for this regards.
MUHAMMAD SAJJAD KAYNI SAUDI ARABIA
adele
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Dec 12, 2011 @ 5:17 pm
I was admitted to hospital 2yrs ago with severe breathing difficulties, pain, nausea, headaches & extreme fatigue. I had been feeling unwell for about 3 days, thought i had caught bug from my daughter, but started deteriorating rapidly. Was diagnosed with pneumonia, septicemia. X-ray showed some pleural fluid so started on antibiotics for 3 days with no effect. Scan showed i had bilateral empyemas and a lot pleural fluid in both sides, had a chest drain inserted in rhs a few days after Christmas 2009, other side was drained using a needle. I was in hopsital for a mnth & on antibiotics for 6mnths. Im still having pain esp wen i stretch or yawn under my ribcage, doctor said he couldnt do anything for it!! Xray showed black shadow, which my doc said could be part of my lung collapsed or just damage to lung!!! Surely I shouldnt be feeling this pain after 2years and what kind of follow up could i get to find cause of pain? I feel so badly let down by treatment i had. Nurses were also reluctant to give me pain relief even tho i was written up for morphine. I found the whole thing a nightmare and still do. I just pray no-one else has to suffer what i endured throughout that time, if i wasnt so weak and in complete agony i would never have allowed myself to be treated so poorly!!
Sharlayne
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Dec 31, 2011 @ 1:01 am
I had breast implants put in 2010 and the surgen cut in to my pleural cavity , it is very pain ful fill the surgen was responable for this ,I did not feel pain much the last year but now I do and it is bad is this surgen responable to fix this please let me know thank you I am not rich and have been saving mony for breast inplants for over 20 years could you please let me know what I can do about this surgen thank you
crash
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Jan 10, 2012 @ 7:19 pm
i recently had a spontaneous lung collapse. I was put to sleep during the insertion of the chest tube. When i woke i was covered in blood on the right side of my body, and was being rushed to another hospitals ICU. Apparently while inserting the chest tube an artery was cut which filled my chest cavity, and lung full of blood. My question is, is this a common occurance or a mistake made by the doctor?
Jacki Scates
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Jan 16, 2012 @ 1:01 am
I had a nodule removed from my left lung on Sept. 7th, 2011. Today 1/15/12 I still have considerable pain in my upper left lung area. It feels like burning and pinching. I don't have an appetite and I'm loosing weight. I have dull ache in my upper abdomen. I also have severe sweating and flushing in my face. I went to a pain clinic just last week and had an injection in the pain area as a nerve block. I still have the pain. I was wishing by this time I would be off all pain medications. I have the feeling something serious is going on but don't know what it could be. Do you have any suggestions or is this normal.
Mdm Chan
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Feb 2, 2012 @ 7:19 pm
I had 4 chest tubes insertion ie chest pleural tube. Two pleural/drainage tubes at upper and lower lungs were also in place (apical and basil tubes). 6x5x4.5cm mediastinal abscess in right paratracheal location with mediastinitis and pneumomediastinum tracking to the lower neck. Loculated right pleural effusion causing mediastinal shift associated with collapsed right lower lobe and partial collapse of right upper and middle lobes. Now, after 2months, the pain is still unbearable. I was given painkillers such as panadol,panadeine tablets and oxynorm capsules and neurobion tablets for 30 days.
What is the next step shldbe taken? Any other medications?
sujud zainur rosyid
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Feb 24, 2012 @ 8:08 am
any different technic in your description about point insertion of the chest tube, in my place the point is anterior of mid axillary lines on 5th intercostalis space. because on that site we know the name of safty triangle (auscultatory triangle, and the musculatoric on that site mare thin so the technic insertion more eazy and the patient less in pain. thank
sd
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May 5, 2012 @ 9:09 am
1.WATER-SEALED BOTTLE FILLD WITH 300CC STEERILE SALINE-WHY NOT MORE OR LESS 300CC?
2.HOW MANY LONG SHOULD BE CHEST TUBE ?
3.SHOULD THE TUBE CLAMPED WHEN WALKING ARROUND?
wow
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Jul 19, 2012 @ 1:13 pm
My lung collapsed and I was taken to emergency. They put a chest tube in and broke an artery that made me bleed more than what I should, they had to give me back 6 units of blood. I was wondering if this was a malpractice or a common mistake that can be acceptable. I will appreciate your comments about it.
F. H
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Jan 12, 2013 @ 11:11 am
If patient on ventilator and has bilateral chest tubes is it possible to remove tubes and chest x rays lung expanded and look normal or must kept until remove pt from ventilator thank
lcf
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Feb 13, 2013 @ 4:16 pm
I had a spontaneous pneumo due to a bleb. Had a CT placed in er on my left side and had horrible immediate pain requiring the CT to be pulled. They then placed a second tube left subclavian area still had horrible stabbing pain, they took this ct out in Cat scan and placed a 3rd CT on day 3below the 2nd . The 3rd CT was the one that I had least amount of pain from but still more pain then the doctors or nurses thought I should have, Went home with CT on day 5 lung was still collapsed. Came back 1 week later and had surgery. I have pain and numbness surrounding the chest tube sites . And get chest pain like I am having a heart attack if I wear a bra or have the seat belt across me.Is this normal??? I Have Horner's Syndrome as a result of the surg and my pain doc has given me the dx of RSD, Is this normal? Could the RSD have been caused by the multiple Chest tubes of the surgery?
barbara
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Feb 13, 2013 @ 9:21 pm
is it ok when the chest tube comes out and there is still air in the pleural space ?
madalyne
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Apr 8, 2013 @ 3:15 pm
23-1-13 I hade a chest tube for a spontanios (Bleb)
I still have pain in my back and rib cage, is this normal and
Is there something I can do to ease the pain
Every now and then I feel like not getting air is this the result after the chest tube, please give me a selution.
Thank you
Brad
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Apr 23, 2013 @ 9:21 pm
Had chest tubes put in 01/13 for a week because of complications from pneumonia. They removed the tubes and said everything was okay, but 3 months I still have a softball size bump on my side where the tubes were. The doc said it may go down or I might have it forever.
Can you tell me what it might be and is it something that may go down in time or with surgery ?
barry
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Jul 10, 2013 @ 9:09 am
Hello, I need to know about how long the pain should last at site of the chest tube insertion after it was removed, it has been 1wk so far. The pain worse when I turn my head to the right and my left arm extended out. The lung had started to collapse due to a fall off of a ladder, my feet was about 8-9ft up on the ladder and top slipped out to the left and I landed on the ladder on my right back side,it brought my shoulders closer together in front of me and caused my sternum and under my left shoulder blade and neck to be very painful. I drove myself about 50 miles to emergency room to get an X-ray for fractured or broken ribs, nothing broken or cracked. They sent me on my way,but had to go back because my neck and left arm started to swell,sounded like rice crispies when touched. All of that pain has pretty much gone away. The accident was June 21 and the tube was in for 2wks, but pain from the tube Site and left armpit area is still very painful. How long should this last? I need to get back to work. Is there an exercise,or stretching that I could do, or do I have to just wait for it to go away. Please I need some help with this. Thank you so very much for your time. Barry
florence
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Feb 11, 2014 @ 5:17 pm
I M Scared had a chest tube insertion for fluid in Nov of this year, going to the doctors office tomorrow and he is going to remove it, he told me to take two pain pills before I go see him. can anyone tell me, if this will really hurt.
Daniel b
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Jul 8, 2014 @ 9:09 am
I had a punctured lung and both blood and air was removed using a chest stain, all went well but but now when I raise my arm a hard lump comes through. Is this to expected and will it go?!
Jose o
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Jul 21, 2014 @ 12:12 pm
I just had my tube removed i can feel and hear alot of gushing from the hole when i b reath or cough, is this normal

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