Tube thoracostomy is the insertion of a tube (chest tube) into the pleural

cavity to drain air, blood, bile, pus, or other fluids. Whether the
accumulation is the result of rapid traumatic filling or insidious malignant
seepage, placement of a chest tube allows for continuous, large volume
drainage until the underlying pathology can be more formally
addressed. The list of specific treatable etiologies is extensive (see
Indications), but without intervention, patients are at great risk for major
morbidity or mortality.
Pneumothorax[6]

Open or closed

Simple or tension[7]
Hemothorax[6]
Hemopneumothorax
Hydrothorax
Chylothorax[8]
Empyema
Pleural effusion[9]
Patients with penetrating chest wall injury who are intubated or
about to be intubated
Considered for those about to undergo air transport who are at
risk for pneumothorax
[5]

C/I
The need for emergent thoracotomy is an absolute
contraindication to tube thoracostomy.
Relative contraindications include the following:
Coagulopathy
Pulmonary bullae
Pulmonary, pleural, or thoracic adhesions
Loculated pleural effusion or empyema
Skin infection over the chest tube insertion site
POSITIONING

The patient should be positioned supine or at a 45 angle.

(Elevating the patient lessens the risk of diaphragm elevation and
consequent misplacement of the chest tube into the abdominal space.)

The arm on the affected side should be abducted and externally

rotated, simulating a position in which the palm of the hand is behind
the patient's head.

A soft restraint or silk tape can be used to secure the arm in this
location. If a restraint is used, make sure that good blood flow to the
hand is present.
TECHNIQUE

Obtain informed consent from the patient or patients

representative.
Assemble the drainage system and connect it to the suction
source. The appearance of bubbles in the water chamber is a sign that
the chest tube drainage device is functioning properly.
Position the patient as described above.
Identify the patient using two identifiers (eg, name and date of
birth). If possible, match the patient's identifiers at his or her bed side
with the identifiers present on a chest x-ray or CT scan that was recently
performed (preferably, one performed at the patient's bed side). Clearly
mark the site of chest tube insertion (right or left).
Identify the fifth intercostal and the midaxillary line.

The skin incision is made in between the midaxillary and

anterior axillary lines over a rib that is below the intercostal level
selected for chest tube insertion.

A surgical marker can be used to better delineate the

anatomy.
Shave excessive hair and apply a preparatory solution to a wide
area of the chest wall as shown below.

Skin preparation and marking.

Wear sterile gloves, gown, hair cover, and goggles or face shield,
and apply sterile drapes to the area.

Administer analgesia.

Administer a systemic analgesic (unless contraindicated).

Use the 25-ga needle to inject 5 mL of the local anesthetic

solution into the skin overlying the initial skin incision, as shown below.

Local anesthesia.

Use the longer needle (23 or, preferably, 27 ga) to infiltrate

about 5 mL of the anesthetic solution to a wide area of subcutaneous
tissue superior to the expected initial incision. Redirect the needle to
the expected course of the chest tube (following the upper border of
the rib below the fifth intercostal space), and inject approximately 10
mL of the anesthetic solution into the periosteum (if bone is
encountered), intercostal muscle, and the pleura.

Aspiration of air, blood, pus, or a combination thereof into

the syringe confirms that the needle entered the pleural cavity.

Use the No. 11 or 10 blade to make a skin incision approximately

4 cm long overlying the rib that is below the desired intercostal level of
entry. The skin incision should be in the same direction as the rib itself.

Skin incision.

Use a hemostat or a medium Kelly clamp to bluntly dissect a tract

in the subcutaneous tissue by intermittently advancing the closed

instrument and opening it, as shown.

Blunt dissection down to the intercostal muscle.

Further blunt dissection down to the

intercostal muscle.

Palpate the tract with a finger as shown, and make sure that the
tract ends at the upper border of the rib above the skin incision.

Palpation of the selected intercostal space

and the superior margin of its inferior rib.

Adding more local anesthetic to the intercostal muscles and

pleura at this time is recommended.

Use a closed large Kelly clamp to pass through the intercostal

muscles and parietal pleura and enter into the pleural space, as shown.

A closed and locked Kelly clamp is used to

enter the chest wall into the pleural cavity. Make sure to guide the clamp over the
upper margin of the rib.

This maneuver requires some force and twisting motion of

the tip of the closed Kelly clamp.

This motion should be done in a controlled manner so the

instrument does not enter too far into the chest, which could injure the
lung or diaphragm.

Upon entry into the pleural space, a rush of air or fluid

should occur.

The Kelly clamp should be opened (while still inside the pleural
space) and then withdrawn so that its jaws enlarge the dissected tract
through all layers of the chest wall as shown. This facilitates passage of

the chest tube when it is inserted.

Once the Kelly clamp enters the pleural cavity, the clamp should be opened to further
enlarge the opening.

Use a sterile, gloved finger to appreciate the size of the tract and
to feel for lung tissue and possible adhesions, as shown in the image
below. Rotate the finger 360 to appreciate the presence of dense
adhesions that cannot be broken and require placement of the chest
tube in a different site, preferably under fluoroscopy (ie, by

interventional radiology).

A finger is
used to palpate the tract and feel for adhesions before insertion of the chest tube.

Measure the length between the skin incision and the apex of the
lung to estimate how far the chest tube should be inserted.

If desired, place a clamp over the tube to mark the

estimated length.

Some prefer to clamp the tube at a distal point, memorizing

the estimated length.

Grasp the proximal (fenestrated) end of the chest tube with the
large Kelly clamp and introduce it through the tract and into the thoracic

cavity as shown.

The proximal end of the

chest tube is held with a Kelly clamp that is used to guide the chest tube through the
tract. The distal end of the chest tube should always be clamped until it is connected
to the drainage device.

Release the Kelly clamp and continue to advance the chest tube
posteriorly and superiorly. Make sure that all of the fenestrated holes in
the chest tube are inside the thoracic cavity.

Connect the chest tube to the drainage device as shown (some

prefer to cut the distal end of the chest tube to facilitate its connection to
the drainage device tubing). Release the cross clamp that is on the
chest tube only after the chest tube is connected to the drainage device.

Connection of the chest tube to a drainage

system.

Before securing the tube with stitches, look for a respirationrelated swing in the fluid level of the water seal device to confirm correct
intrathoracic placement.

Secure the chest tube to the skin using 0 or 1-0 silk or nylon

stitches, as depicted below.

A 0 or 1-0

silk or nylon suture is used to secure the chest tube to the skin.

Securing sutures: Two separate through-and-through,

simple, interrupted stitches on each side of the chest tube are
recommended. This technique ensures tight closure of the skin
incision and prevents routine patient movements from dislodging the
chest tube.

Each stitch should be tightly tied to the skin, then wrapped

tightly around the chest tube several times to cause slight indentation,
and then tied again.

Sealing suture: A central vertical mattress stitch with ends

left long and knotted together can be placed to allow for sealing of the
tract once the chest tube is removed.

Place petrolatum (eg, Vaseline) gauze over the skin incision as

shown.

Apply petrolatum (eg, Vaseline)

gauze over the skin incision.

Create an occlusive dressing to place over the chest tube by

turning regular gauze squares (4 x 4 in) into Y-shaped fenestrated
gauze squares and using 4-in adhesive tape to secure them to the
chest wall, as shown below. Make sure to provide enough padding
between the chest tube and the chest wall.

Preparation of a Y-shaped fenestrated drain

gauze from regular gauze (4 x 4 in).

Apply
support gauze dressing around the chest tube and secure it to the chest wall with 4in adhesive tape.

Strap the emerging chest tube on to the lower trunk with a

"mesentry" fold of adhesive tape, as this avoids kinking of the tube as it
passes through the chest wall. It also helps reduce wound site pain and

discomfort for the patient. All connections are then taped in their long
axis to avoid disconnections.

Obtain a chest radiograph, like the one below, to ensure correct

placement of the chest tube.

PNEUMOTHORAX

Pneumothorax, the presence of air within the pleural space, is

considered to be one of the most common forms of thoracic disease. It
is classified as spontaneous (not caused by trauma), traumatic, or
iatrogenic (see the images below).[1, 2, 3]

A large, right-sided pneumothorax has

occurred from a rupture of a subpleural bleb.

A true pneumothorax line. Note that the

visceral pleural line is observed clearly, with the absence of vascular marking beyond
the pleural line.

Spontaneous pneumothorax may be either primary (occurring in

persons without clinically or radiologically apparent lung disease) or
secondary (in which lung disease is present and apparent). Most
individuals with primary spontaneous pneumothorax (PSP) have
unrecognized lung disease; many observations suggest that
spontaneous pneumothorax often results from rupture of a subpleural
bleb.
Traumatic pneumothorax is caused by penetrating or blunt trauma to
the chest, with air entering the pleural space directly through the chest

wall, through visceral pleural penetration, or through alveolar rupture

resulting from sudden compression of the chest.
Iatronic pneumothorax results from a complication of a diagnostic or
therapeutic intervention. With the increasing use of invasive diagnostic
procedures, iatrogenic pneumothorax likely will become more common,
although most cases are of little clinical significance.
Complications of pneumothorax

In most reported series, the rate of recurrence of spontaneous

pneumothorax on the same side is as much as 30%; on the
contralateral side, the rate of recurrence is approximately 10%.
Other complications include the following:

Reexpansion pulmonary edema

Bronchopleural fistula - Occurs in 3-5% of patients

Pneumomediastinum and pneumopericardium

Tension pneumothorax may occur after spontaneous pneumothorax,
although it is more common after traumatic pneumothorax or with
mechanical ventilation.
Preferred examination

Chest radiography is the first investigation performed to assess

pneumothorax, because it is simple, inexpensive, rapid, and
noninvasive; however, it is much less sensitive than chest computed
tomography (CT) scanning in detecting blebs or bullae or a small
pneumothorax.[4, 5, 6, 7, 8, 9, 10]
RADIOGRAPHY

The diagnosis of pneumothorax is established by demonstrating the

outer margin of the visceral pleura (and lung), known as the pleural line,
separated from the parietal pleura (and chest wall) by a lucent gas
space devoid of pulmonary vessels. The pleural line appears in the
image below).

A true pneumothorax line. Note that the

visceral pleural line is observed clearly, with the absence of vascular marking beyond
the pleural line.

The pleural line may be difficult to detect with a small pneumothorax

unless high-quality posteroanterior and lateral chest films are obtained

and viewed under a bright light. A skin fold may mimic the pleural line;
usually, the patient is asymptomatic (see the image below).

Note that although a skin fold can mimic a

subtle pneumothorax, lung markings are visible beyond the skin fold.

In erect patients, pleural gas collects over the apex, and the space
between the lung and the chest wall is most notable at that point (see
the image below).

A large, right-sided pneumothorax has

occurred from a rupture of a subpleural bleb.

In the supine position, the juxtacardiac area, the lateral chest wall, and
the subpulmonic region are the best areas to search for evidence of
pneumothorax (see the image below). The presence of a deep
costophrenic angle on a supine film may be the only sign of
pneumothorax; this has been termed the deep sulcus sign.

Deep sulcus sign in a supine patient in the ICU.

The pneumothorax is subpulmonic.

When a suggested pneumothorax is not definitively observed on an

inspiratory film, an expiratory film may be helpful. At end expiration, the
constant volume of the pneumothorax gas is accentuated by the
reduction of the hemithorax, and the pneumothorax is recognized more
easily. Similar accentuation may be obtained with lateral decubitus
studies of the appropriate side (for a possible left pneumothorax, a right
lateral decubitus film of the chest should be obtained, with the beam
centered over the left lung).
The most common radiographic manifestations of tension
pneumothorax are mediastinal shift, diaphragmatic depression, and rib
cage expansion (see the image below).

An older man admitted to ICU

postoperatively. Note the right-sided pneumothorax induced by the incorrectly
positioned small-bowel feeding tube in the right-sided bronchial tree. Marked
depression of the right hemidiaphragm is noted, and mediastinal shift is to the left
side, suggestive of tension pneumothorax. The endotracheal tube is in a good
position.

Any significant degree of displacement of the mediastinum from the

midline position on maximum inspiration, as well as any depression of
the diaphragm, should be taken as evidence of tension (see the image
below), although a definite diagnosis of tension pneumothorax is difficult
to make on the basis of radiographic findings. The degree of lung
collapse is an unreliable sign of tension, since underlying lung disease
may prevent collapse even in the presence of tension.

Right main stem intubation resulting in left-sided

tension pneumothorax, right mediastinal shift, deep sulcus sign, and subpulmonic
pneumothorax

Pleural effusions occur coincident with pneumothorax in 2025% of

patients, but they usually are quite small. Hemopneumothorax occurs in
23% of patients with spontaneous pneumothorax. Bleeding is believed
to represent rupture or tearing of vascular adhesions between the
visceral and parietal pleura as the lung collapses.
False positives/negatives

Differentiating the pleural line of a pneumothorax from that of a skin

fold, clothing, tubing, or chest wall artifact is important. Careful
inspection of the film may reveal that the artifact extends beyond the
thorax or that lung markings are visible beyond the apparent pleural
line. In the absence of underlying lung disease, the pleural line of a
pneumothorax usually parallels the shape of the chest wall (see the
images below).

A true pneumothorax line. Note that the

visceral pleural line is observed clearly, with the absence of vascular marking beyond

the pleural line.

Note that although a skin
fold can mimic a subtle pneumothorax, lung markings are visible beyond the skin
fold.

Artifactual densities usually do not parallel the course of the chest wall
over their entire length. Avascular bullae or thin-walled cysts may be
mistaken for a pneumothorax. The pleural line caused by a
pneumothorax usually is bowed at the center toward the lateral chest
wall. Unlike in pneumothorax, the inner margins of bullae or cysts
usually are concave rather than convex and do not conform exactly to
the contours of the costophrenic sulcus. A pneumothorax with a pleural
adhesion also may simulate bullae or lung cysts.
DOB = INTERCOSTAL AND SUBCOSTAL RETRACTIONS