tube thoracostomy for Rx of pneumothorax and haemothorax

see also:

• pneumothorax
• trauma to the chest
• links to videos on nearly everything you need to know about chest drains, thoracotomy, underwater seal drainage courtesy of Life In The Fast Lane
• how to secure the chest tube
• RCH guideline - intercostal catheter insertion
• The University of Queensland Portal for Chest Tube Insertion

• pleural decompression via inserting an intercostal catheter is a core emergency procedure which is often performed poorly.

• pleural decompression is beneficial for:
  • patients with haemodynamic or respiratory compromise with coinciding pneumothorax or haemothorax
  • patients with pneumothorax who are mechanically ventilated or planned to go to theatre for GA

• no absolute C/I to insertion if the patient has a tension pneumothorax or is in severe respiratory distress
• anticoagulation or bleeding diasthesis is a relative C/I, particularly for elective procedures
• CT-guided technique should be used in less urgent cases if either:
  • adhesions from infection
  • previous pleurodesis
  • lung transplant recipient

• in the past size 16-24F has been the standard for spontaneous pneumothorax, however:
  • British Thoracic Society guideline suggests 10-14F is adequate for these patients
  • many prefer a 28F if there is a high risk of large air leak due to a bronchopleural fistula such as in:
    • pneumothorax occurring during mechanical ventilation
    • patients with severe underlying lung disease
• 28-32F catheters are usually used for patients with traumatic pneumothoraces to ensure adequate drainage of blood

• lateral placement in the fourth or fifth intercostal space anterior to the mid-axillary line is considered optimal
  • the 5th intercostal space is just below the nipple in the male, or at the level of the xiphisternum
  • “safe triangle” for insertion:
    • bounded by lateral border of pectoralis major anteriorly, the lateral border of lattismus dorsi posteriorly and the 5th intercostal space inferiorly - ie. the apex of the triangle is in the axilla
    • new Mid-Arm Point (MAP) simple technique to identify 5th ICS
• use aseptic technique with procedure tray near operator's dominant hand and adequate analgesia (eg. ketamine) / patient restraint to avoid patient contaminating field
• initial 2-4cm incision parallel with ribs
• blunt dissection is carried out superiorly over the rib to avoid the intercostal neurovascular bundle which runs below each rib
• arterial forceps are then pushed through the pleura (with a pronounced give, usually followed by a hiss of air), and then the forceps opened to make a hole in the pleura.
• a finger is inserted to ensure there are no tissues deep to the ribs
• digital decompression of the pleural space identifies that no adhesions are present and will cause the lung to fall away.
  • insertion of a finger with 360 degrees rotation is a pre-requisite of all tube thoracostomies
  • if adhesions are felt the insertion site should be re-located
• the intercostal catheter WITHOUT trocar is introduced in a postero-superior direction through the intercostal space and advanced without force into the pleural space.
• the track through the sub-cutaneous tissues should already be heading superiorly
• the tube is guided into the chest cavity with curved forceps and once in these are removed and the tube is pushed through to 10-15cm depending upon body habitus.
• tubes that are placed superiorly have a reduced likelihood of intrafissural placement
• a superiorly directed tube can easily flick down to a more inferiorly directed position if the skin suture forces it that way and care should be taking when suturing.
• the correctly placed tube should fog.
• when connected to an underwater seal drain prior to suction being applied, the water level should swing with inspiration/expiration to confirm intrapleural placement
• tube should be secured to the skin with a heavy, braided suture.
• tubing is then also secured to the patient with a mesentery style taping to take pressure off the suture tie and minimise risk of tube disconnection.
• confirmatory CXR is done with particular emphasis to ensure the most proximal tube portal is within the thoracic cavity (this portal is shown as a gap in the radioopaque line)
• whenever possible, blunt thoracic trauma patients should undergo definitive CT imaging after tube thoracostomy to check for appropriate tube position.¹⁾

• tube malposition occurs in up to 20% such as:
  • extrapleural placement
    • all side holes should be within the pleural space
    • tube should be straight without kinks
    • tube should be directed at apex of lung posteriorly
  • intrafissural placement - if the tube is not swinging or draining it will require replacement
  • intrapulmonary placement
    • lung parenchyma penetration (0.2-0.6%)
    • usually associated with a large, ongoing air leak, and will require replacement of tube
  • mediastinal impingement or penetration
    • if post-insertion massive blood loss through the tube or imaging appearance suggests intravascular placement the tube should be clamped and left in situ until urgent thoracic surgical control can be achieved.
    • perforation of right ventricle, right atrium
    • chest tube compression of right ventricle causing cardiac failure
    • mediastinal perforation with contralateral hemothorax and pneumothorax
  • trans-diaphragmatic or intra-bowel placement
    • more likely if an ipsilateral diaphragmatic tear is present.
    • digital examination through left sided thoraco-abdominal stab wounds had a sensitivity of 96% and positive predictive value of 91% for lesions of the left hemi diaphragm
    • penetration into abdominal organs (liver, spleen)
• trauma to the intercostal neurovascular bundle
• infection / empyema (1-3%)
  • placement of the instrument tray close to the thoracic incision alongside the operator’s dominant hand reduces hand to incision site distance and contamination opportunity.
  • control patient pain and avoid patient interference with and contamination of the procedural field
  • a frequent source of contamination occurs when the non-sterile drainage system is connected to the chest tube before skin suturing is completed.
• re-expansion pulmonary edema (RPE):
  • represents a potentially life-threatening complication (mortality up to 20%) of tube thoracostomy
  • usually occurs within 24 hours but may be delayed
  • more likely after evacuation of > 1L pleural fluid, thus many clamp the tube after 1-1.5L drained, wait 2-4hrs before unclamping the tube
• clotting, kinking or dislodgment of tube

• Best Bets - tube thoracostomy ²⁾