Key points
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Tube thoracostomy is the insertion of a tube into the pleural cavity to facilitate drainage of air and fluid.
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Tube thoracostomy can be used as both a diagnostic and a therapeutic intervention.
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Sterile surgical technique is required for tube thoracostomy in order to avoid infectious complications.
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Careful tube thoracostomy positioning is needed for adequate drainage of air or fluid.
Introduction
The procedure of tube thoracostomy is the insertion of a tube into the pleural cavity to facilitate drainage of air and fluid. The purpose of this article is to highlight the role of tube thoracostomy in the management of surgical patients. A generalized approach and description of indications, contraindications, procedural steps, controversies, and common pitfalls are provided. A brief description of posttube thoracostomy management is also included.
Indications
Tube thoracostomy may serve the role of either a diagnostic or a therapeutic intervention. In critically ill patients with undifferentiated shock or for patients in extremis, rapid bilateral chest tube drainage is a useful procedure for guiding diagnostic evaluation. Other indications for tube thoracostomy include treatment of pneumothorax, hemothorax, hemopneumothorax, pleural effusion, empyema, chylothorax, and hydrothorax, and for the prophylactic decompression of patients undergoing air transport.
Contraindications
There are no absolute contraindications for tube thoracostomy. Relative contraindications include coagulopathy, pulmonary bullae, dense pleural adhesions, and a loculated pleural effusion.
Introduction
The procedure of tube thoracostomy is the insertion of a tube into the pleural cavity to facilitate drainage of air and fluid. The purpose of this article is to highlight the role of tube thoracostomy in the management of surgical patients. A generalized approach and description of indications, contraindications, procedural steps, controversies, and common pitfalls are provided. A brief description of posttube thoracostomy management is also included.
Indications
Tube thoracostomy may serve the role of either a diagnostic or a therapeutic intervention. In critically ill patients with undifferentiated shock or for patients in extremis, rapid bilateral chest tube drainage is a useful procedure for guiding diagnostic evaluation. Other indications for tube thoracostomy include treatment of pneumothorax, hemothorax, hemopneumothorax, pleural effusion, empyema, chylothorax, and hydrothorax, and for the prophylactic decompression of patients undergoing air transport.
Contraindications
There are no absolute contraindications for tube thoracostomy. Relative contraindications include coagulopathy, pulmonary bullae, dense pleural adhesions, and a loculated pleural effusion.
Surgical technique
Preoperative planning
Tube thoracostomy insertion is often performed in emergency conditions. Attention to detail, including proper infection prevention measures and understanding of anatomy, is important for avoidance of complications. Clinical examination and review of available radiographic studies, including chest radiograph, computed tomographic (CT) scan, and ultrasound, allow for preoperative planning to ensure optimal tube placement. The clinical indication combined with radiographic studies will dictate the size of the chest tube, site of insertion, and intrapleural positioning of the tube. Small pigtail drains are placed using CT or ultrasound guidance using the Seldinger technique and are typically used for pneumothorax or simple effusions. This technique is described elsewhere. In cases where the thoracostomy tube is placed for drainage of blood or pus, a larger tube is indicated to allow proper drainage and to prevent tube occlusion. In most cases, a 32-French chest tube is adequate. Larger surgical drains are placed under direct, open surgical approach. Anatomic variations and abnormalities may dictate alternative sites for tube insertion.
Procedure risks
Details of procedural risks should be reviewed with the patient or substitute person in charge of decisions. Risks for tube thoracostomy include the following:
- 1.
Bleeding
- 2.
Infection
- a.
Local incision site
- b.
Empyema
- a.
- 3.
Improper placement
- a.
Injury to adjacent organs (heart, spleen, liver, stomach, lung, diaphragm)
- b.
Tube malposition
- i.
Too deep, causing irritation to the pleura
- ii.
Too superficial, side ports of tube in subcutaneous tissues or open to atmosphere
- i.
- a.
Preparation and patient positioning
Position the patient supine with the ipsilateral arm abducted and the elbow flexed to enable hand positioning over the head. It is useful to secure the patient’s hand with tape or wrist restraints to avoid inadvertent drift into the surgical field ( Fig. 1 ). Once the patient is properly positioned, the skin surface is prepared using chlorhexidine or alternatively a 10% povidone-iodine solution. Application of the skin preparation should extend from the costal margin to the axilla and from the mid chest to the inferior axillary line. Standard full-body draping material should be used. Finally, the provider should wear full protective gear, including hair net, mask, eye protection, sterile gown, and surgical gloves.
Analgesia
Tube thoracostomy insertion is an uncomfortable procedure and may require administration of systemic analgesia and sedation in addition to local analgesia. Intravenous analgesia should be titrated to provide comfort and to avoid respiratory depression. Reasonable choices for analgesia include morphine or fentanyl combined with midazolam or with ketamine. The authors recommend generous use of 1% lidocaine to locally anesthetize the skin surface and subcutaneous tissues. Care should be taken not to exceed maximum dosing for lidocaine (maximum of 7 mg/kg of lidocaine HCl with epinephrine and 4.5 mg/kg of lidocaine HCl without epinephrine) and should be done at one intercostal space below the desired intercostal level for the tube insertion. This offset allows for tunneling of a dissection plane before placement of the tube into the pleural space. The tunnel helps to prevent re-entry of air once the tube is removed. Local anesthetic should also be injected around the periosteum of the rib and at the parietal-pleural interface. Alternatively, the patient may undergo an intercostal nerve block. Nerve block is most beneficial in patients with multiple rib fractures.
Surgical approach
Optimal placement of a tube thoracostomy is important to ensure adequate re-expansion of a collapsed lung or drainage of a pleural effusion or hemothorax. The indication for tube thoracostomy placement dictates the tube insertion site on the chest wall and positioning of the chest tube within the pleural space. The main determinants of simple chest tube placement are the presence of fluid, blood, or air. Fluid and air collections accumulate in the dependent and nondependent portions of the thoracic cavity, respectively. Complex loculated fluid collections are often best drained with real-time image-guided techniques described elsewhere. The following discussion outlines the surgical approach for tube thoracostomy placed for pneumothorax, hemothorax, and pleural effusions.
Pneumothorax
The tube thoracostomy is at the fourth or fifth intercostal space in the anterior axillary or midaxillary line. In male and female patients, this corresponds to the nipple line and inframammary fold, respectively. The tube should be directed anteriorly to avoid the tube becoming walled off within the intraloblar fissure and becoming nonfunctional.
Hemothorax
The surface landmarks for a hemothorax are the same as described above. The tube, however, should be directed posteriorly to enhance drainage of blood.
Pleural effusion
The surface landmarks for a pleural effusion are the same as described above. For optimal drainage of a pleural effusion, the tube should be directed toward the lower chest.
The equipment used for a tube thoracotomy is outlined in Table 1 .
| Surgical equipment | Procedure equipment |
|---|---|
|
|
Surgical procedure
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The surgical steps for tube thoracostomy are as follows:
- 1.
Patient position
- a.
Palpate the chest wall to identify the fourth or fifth intercostal space.
- b.
Mark the surgical site location using a skin marking pen.
- a.
- 2.
Skin preparation
- a.
Surgical area is prepared and draped.
- a.
- 3.
Local anesthetic
- a.
1% lidocaine is injected into the skin surface and subcutaneous tissues
- a.
- 4.
Incision
- a.
Oblique incision is made in the direction of the rib over the premarked area on the skin using a no. 11 blade scalpel. The incision should measure 4 to 5 cm in length.
- a.
- 5.
Dissection
- a.
Blunt dissection is made using a hemostat down to the intercostal muscle over the top surface of the rib. Care should be taken to avoid accessing the pleural space directly below the rib, because this may cause injury to the intercostal neurovascular bundle.
- b.
Advance a closed hemostat through the intercostal muscles and parietal pleura and enter into the pleural space. This technique often requires significant force. Control the hemostat with both hands to avoid plunging into the pleural space and to avoid injury to the intercostal neurovascular bundle. The hemostat should be withdrawn wide open to allow dilation of the tract. Dilation of the tract will help to accommodate subsequent tube placement.
- c.
Once in the pleural space, note any release of air, fluid, or blood.
- a.
- 6.
Pleural sweep
- a.
Insert a finger into pleural cavity and sweep the pleural surface circumferentially for adhesions. The incision and tract should be wide enough to easily accommodate the surgeon’s finger and a large-bore chest tube.
- a.
- 7.
Chest tube insertion
- a.
The distal end of the chest tube (32–36 Fr) is clamped with a large Kelly hemostat to avoid spillage of fluid through the tube once it is inserted. The fenestrated end of the tube is then inserted through the dissection tract into the pleural space. The authors recommend using an index finger as a guide for tube placement. For example, the index finger can be used to ensure the tube is within the pleural space and to ensure the tube is appropriately directed (anterior or posterior).
- b.
Ensure all fenestrated holes are within the pleural space. Ensure the tube enters between the ribs and into the pleural space and has not dissected in the subcutaneous tissues behind the thoracic cavity or has not curled in the subcutaneous tissues.
- a.
- 8.
Secure chest tube
- a.
The chest tube is secured to the chest wall with a no. 1 silk suture.
- b.
The authors suggest using a U-stitch technique for skin closure and securing the chest tube.
- a.
- 9.
Chest tube drainage
- a.
Once the chest tube is secured to the skin, the distal end of the chest tube is secured to a chest tube collection system. After the connection is established, the Kelly clamp is released.
- a.
- 10.
Chest tube dressings
- a.
Vaseline gauze is placed over the skin incision, followed by application of an occlusive dressing.
- a.
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Postprocedure steps include the following:
- 11.
Chest tube drainage
- a.
Chest tube output should be monitored closely for immediate drainage volume and continued drainage for the first several hours. Initial high output of blood (greater than 1.5 L) or persistent bleeding (greater than 200 cc/h) may indicate the need for thoracotomy for control of bleeding.
- a.
- 12.
Chest radiograph
- a.
A postchest tube insertion chest radiograph ( Fig. 2 ) is done to confirm the position of the tube and the resolution of the underlying pathologic abnormality.
- a.
