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TubeThoracostomy:Overview,Indications,Contraindications

TubeThoracostomy
Author:GilZShlamovitz,MD,FACEPChiefEditor:RylandPByrd,Jr,MDmore...
Updated:Apr28,2014

Overview
Traumaistheleadingcauseofdeathforindividualsyoungerthan40yearsofage,
withapproximately140,000deathsannuallyintheUnitedStatesalone. [1]Ofthese
deaths,thoracicinjuriesareprimarilyresponsiblefor25%ofcases[2]andarea
majorcontributingfactorinupto75%ofcases. [1]However,mostthoracicinjuries
maybeeffectivelytreatedwithtubethoracostomyandsimplefluidresuscitation. [3,
4]

Tubethoracostomyistheinsertionofatube(chesttube)intothepleuralcavityto
drainair,blood,bile,pus,orotherfluids. [5]Whethertheaccumulationofairorfluid
istheresultofrapidtraumaticfillingwithairorbloodoraninsidiousmalignant
exudativefluid,placementofachesttubeallowsforcontinuous,largevolume
drainageuntiltheunderlyingpathologycanbemoreformallyaddressed.Thelistof
specifictreatableetiologiesisextensive(seeIndications),butwithoutintervention,
patientsareatgreatriskformajormorbidityormortality.

Indications
Seethelistbelow:
Pneumothorax[6]
Openorclosed
Simpleortension[7]
Hemothorax[6]
Hemopneumothorax
Hydrothorax
Chylothorax[8]
Empyema
Pleuraleffusion[9]
Patientswithpenetratingchestwallinjurywhoareintubatedorabouttobe
intubated
Consideredforthoseabouttoundergoairtransportwhoareatriskfor
pneumothorax

Contraindications
Seethelistbelow:
Theneedforemergentthoracotomyisanabsolutecontraindicationtotube
thoracostomy.
Relativecontraindicationsincludethefollowing:
Coagulopathy
Pulmonarybullae
Pulmonary,pleural,orthoracicadhesions
Loculatedpleuraleffusionorempyema
Skininfectionoverthechesttubeinsertionsite

Equipment
Seethelistbelow:
Chesttubedrainagedevicewithwaterseal(autotransfuserunitisanoption)
Suctionsourceandtubing
Sterilegloves
Preparatorysolution
Steriledrapes
Surgicalmarker
Lidocaine1%withepinephrine
Syringes,1020mL(2)
Needle,25gauge(ga),5/8in
Needle,23ga,1.5inor27ga,1.5inforinstillinglocalanesthesia
Blade,No.10,onahandle
LargeandmediumKellyclamps
LargecurvedMayoscissors
Largestraightsuturescissors
Silkornylonsuture,0or10
Needledriver
Vaselinegauze
Gauzesquares,4x4in(10)
Sterileadhesivetape,4inwide

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Chesttubeofappropriatesize
Man2832F
Woman28F
Child1228F
Infant1216F
Neonate1012F

Positioning
Seethelistbelow:
Thepatientshouldbepositionedsupineorata45angle.(Elevatingthe
patientlessenstheriskofdiaphragmelevationandconsequent
misplacementofthechesttubeintotheabdominalspace.)
Thearmontheaffectedsideshouldbeabductedandexternallyrotated,
simulatingapositioninwhichthepalmofthehandisbehindthepatient's
head.
Asoftrestraintorsilktapecanbeusedtosecurethearminthislocation.If
arestraintisused,makesurethatgoodbloodflowtothehandispresent.

Technique
Seethelistbelow:
Obtaininformedconsentfromthepatientorpatientsrepresentativeexcept
whenurgentplacementisrequired.
Assemblethedrainagesystemandconnectittothesuctionsource.The
appearanceofbubblesinthewaterchamberisasignthatthechesttube
drainagedeviceisfunctioningproperly.
Positionthepatientasdescribedabove.
Identifythepatientusingtwoidentifiers(eg,nameanddateofbirth).If
possible,matchthepatient'sidentifiersathisorherbedsidewiththe
identifierspresentonachestradiographsorcomputerizedtomograms(CT)
thatwasrecentlyperformed.Clearlymarkthesiteofchesttubeinsertion
(rightorleft).
Identifythefifthintercostalandthemidaxillaryline.
Theskinincisionismadeinbetweenthemidaxillaryandanterior
axillarylinesoveraribthatisbelowtheintercostallevelselectedfor
chesttubeinsertion.
Asurgicalmarkercanbeusedtobetterdelineatetheanatomy.
Shaveexcessivehairandapplyapreparatorysolutiontoawideareaofthe
chestwallasshownbelow.

Skinpreparationandmarking.

Wearsterilegloves,gown,haircover,andgogglesorfaceshield,andapply
steriledrapestothearea.
Administeranalgesia.
Administerasystemicanalgesic(unlesscontraindicated).
Usethe25ganeedletoinject5mLofthelocalanestheticsolution
intotheskinoverlyingtheinitialskinincision,asshownbelow.

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Localanesthesia.

Usethelongerneedle(23or,preferably,27ga)toinfiltrateabout5
mLoftheanestheticsolutiontoawideareaofsubcutaneoustissue
superiortotheexpectedinitialincision.Redirecttheneedletothe
expectedcourseofthechesttube(followingtheupperborderofthe
ribbelowthefifthintercostalspace),andinjectapproximately10mL
oftheanestheticsolutionintotheperiosteum(ifboneis
encountered),intercostalmuscle,andthepleura.
Aspirationofair,blood,pus,oracombinationthereofintothesyringe
confirmsthattheneedleenteredthepleuralcavity.
UsetheNo.11or10bladetomakeaskinincisionapproximately4cmlong
overlyingtheribthatisbelowthedesiredintercostallevelofentry.Theskin
incisionshouldbeinthesamedirectionastheribitself.

Skinincision.

UseahemostatoramediumKellyclamptobluntlydissectatractinthe
subcutaneoustissuebyintermittentlyadvancingtheclosedinstrumentand
openingit,asshown.

Bluntdissectiondowntotheintercostalmuscle.

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Furtherbluntdissectiondowntotheintercostalmuscle.

Palpatethetractwithafingerasshown,andmakesurethatthetractends
attheupperborderoftheribabovetheskinincision.Insertionofthechest
tubeascloseaspossibletotheupperborderoftheribwillminimizetherisks
ofinjurytothenerveandbloodvesselsthatfollowthelowerborderofeach
rib.

Palpationoftheselectedintercostalspaceandthesuperiormarginofitsinferiorrib.

Addingmorelocalanesthetictotheintercostalmusclesandpleuraatthis
timeisrecommended.
UseaclosedlargeKellyclamptopassthroughtheintercostalmusclesand
parietalpleuraandenterintothepleuralspace,asshown.

AclosedandlockedKellyclampisusedtoenterthechestwallintothepleuralcavity.
Makesuretoguidetheclampovertheuppermarginoftherib.

Seethelistbelow:
Thismaneuverrequiressomeforceandtwistingmotionofthetipof
theclosedKellyclamp.
Thismotionshouldbedoneinacontrolledmannersotheinstrument
doesnotentertoofarintothechest,whichcouldinjurethelungor

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diaphragm.
Uponentryintothepleuralspace,arushofairorfluidshouldoccur.
TheKellyclampshouldbeopened(whilestillinsidethepleuralspace)and
thenwithdrawnsothatitsjawsenlargethedissectedtractthroughalllayers
ofthechestwallasshown.Thisfacilitatespassageofthechesttubewhenit
isinserted.

OncetheKellyclampentersthepleuralcavity,theclampshouldbeopenedtofurther
enlargetheopening.

Useasterile,glovedfingertoappreciatethesizeofthetractandtofeelfor
lungtissueandpossibleadhesions,asshownintheimagebelow.Rotatethe
finger360toappreciatethepresenceofdenseadhesionsthatcannotbe
brokenandrequireplacementofthechesttubeinadifferentsite,preferably
underfluoroscopy(ie,byinterventionalradiology).

Afingerisusedtopalpatethetractandfeelforadhesionsbeforeinsertionofthechest
tube.

Measurethelengthbetweentheskinincisionandtheapexofthelungto
estimatehowfarthechesttubeshouldbeinserted.
Ifdesired,placeaclampoverthetubetomarktheestimatedlength.
Someprefertoclampthetubeatadistalpoint,memorizingthe
estimatedlength.
Grasptheproximal(fenestrated)endofthechesttubewiththelargeKelly
clampandintroduceitthroughthetractandintothethoraciccavityas
shown.

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TheproximalendofthechesttubeisheldwithaKellyclampthatisusedtoguidethe
chesttubethroughthetract.Thedistalendofthechesttubeshouldalwaysbeclamped
untilitisconnectedtothedrainagedevice.

ReleasetheKellyclampandcontinuetoadvancethechesttubeposteriorly
andsuperiorly.Makesurethatallofthefenestratedholesinthechesttube
areinsidethethoraciccavity.
Connectthechesttubetothedrainagedeviceasshown(someprefertocut
thedistalendofthechesttubetofacilitateitsconnectiontothedrainage
devicetubing).Releasethecrossclampthatisonthechesttubeonlyafter
thechesttubeisconnectedtothedrainagedevice.

Connectionofthechesttubetoadrainagesystem.

Beforesecuringthetubewithstitches,lookforarespirationrelatedswingin
thefluidlevelofthewatersealdevicetoconfirmcorrectintrathoracic
placement.
Securethechesttubetotheskinusing0or10silkornylonstitches,as
depictedbelow.

A0or10silkornylonsutureisusedtosecurethechesttubetotheskin.

Seethelistbelow:

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Securingsutures:Twoseparatethroughandthrough,simple,
interruptedstitchesoneachsideofthechesttubearerecommended.
Thistechniqueensurestightclosureoftheskinincisionandprevents
routinepatientmovementsfromdislodgingthechesttube.
Eachstitchshouldbetightlytiedtotheskin,thenwrappedtightly
aroundthechesttubeseveraltimestocauseslightindentation,and
thentiedagain.
Sealingsuture:Acentralverticalmattressstitchwithendsleftlong
andknottedtogethercanbeplacedtoallowforsealingofthetract
oncethechesttubeisremoved.
Placepetrolatum(eg,Vaseline)gauzeovertheskinincisionasshown.

Applypetrolatum(eg,Vaseline)gauzeovertheskinincision.

Createanocclusivedressingtoplaceoverthechesttubebyturningregular
gauzesquares(4x4in)intoYshapedfenestratedgauzesquaresandusing
4inadhesivetapetosecurethemtothechestwall,asshownbelow.Make
suretoprovideenoughpaddingbetweenthechesttubeandthechestwall.

PreparationofaYshapedfenestrateddraingauzefromregulargauze(4x4in).

Applysupportgauzedressingaroundthechesttubeandsecureittothechestwallwith
4inadhesivetape.

Straptheemergingchesttubeontothelowertrunkwitha"mesentry"foldof
adhesivetape,asthisavoidskinkingofthetubeasitpassesthroughthe
chestwall.Italsohelpsreducewoundsitepainanddiscomfortforthe
patient.Allconnectionsarethentapedintheirlongaxistoavoid
disconnections.

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Obtainachestradiograph,liketheonebelow,toensurecorrectplacement
ofthechesttube.

Chesttubeingoodposition.

SeeTubeThoracostomyManagementforremovaltechniques.

Pearls
Seethelistbelow:
Incasesofhighpressureempyemaorpleuraleffusion,removalof50200
mLoffluidusingasyringeanda14ganeedle,asshownbelow,might
preventhighpressuresprayingoftheaccumulatedfluidoncethepleural
spaceisenteredwiththesurgicalinstrument.

Aneedleandasyringeareusedtodecompressthepleuralcavityinacaseoftension
empyema.

Sincetheintercostalvesselsandnerverunontheinferiormarginofeachrib,
incisionandtunnelingshouldbeperformedovertherib.Insertionofthe
chesttubeshouldbeperformedimmediatelyaboveandasclosetothe
superiorribmarginaspossibleinordertominimizetherisksofinjurytothe
nerveandbloodvesselsthatfollowthelowermarginofeachrib.
Errorsthatarecommonlyobservedbuteasilyavoidableincludeinadequate
volumeoflocalanesthetic,failuretowaitadequatetimeforanestheticto
takeeffect,andtoosmallanincision.
A"safetriangle"(shownbelow)hasbeendescribedasthepreferredsiteof
insertion.Thisisthetriangleborderedbytheanteriorborderofthelatissimus
dorsi,thelateralborderofthepectoralismajormuscle,alinesuperiortothe
horizontallevelofthenipple,andanapexbelowtheaxilla. [10]

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Thesafetriangle.

Smallboredrainsarerecommended,astheyaremorecomfortablethan
largerboretubes,butnoevidenceindicatesthateitheristherapeutically
superior.Largeboredrainsarerecommendedfordrainageofacute
hemothoraxandtomonitorfurtherbloodloss. [10]

Complications
Minorcomplicationsofthoracostomytubeplacementsuchas
unresolved/reaccumulationofpneumothoraxormisplacementofthetube(too
deep/kinked)arecommonandapproachapproximately30%. [11]
Improperplacement
Horizontal(overthediaphragm)Acceptableforhemothoraxshould
berepositionedforpneumothorax(Seetheimagebelow.)

Thechesttubeisangulated,overlyingthediaphragm.

SubcutaneousMustberepositioned
Placedtoofarintothechest(againsttheapicalpleura)Shouldbe
retracted
PlacedintotheabdominalspaceShouldberemoved
Bleeding
LocalUsuallyrespondstodirectpressure
Hemothorax(lungvsintercostalarteryinjury)Mightrequire
thoracotomyifitdoesnotresolvespontaneously
Hemoperitoneum(liverorspleeninjury)Requiresemergentlaparotomy
Organpenetration(usuallyrequiressurgicalrepair)
Stomach,colon,ordiaphragmOccursasaresultofunrecognized
diaphragmatichernia
LungOccursasaresultofpleuraladhesionsoruseofa
thoracostomytubetrocar
LiverorspleenSeehemoperitoneumabove
Tubedislodgement
EmpyemaChesttube(foreignobject)couldintroducebacteriaintothe
pleuralspace
RetainedpneumothoraxorhemothoraxMightrequireinsertionofasecond
chesttube
Reexpansionpulmonaryedemaisarareandpotentiallyfatalcomplication
thecanoccuraftertreatmentofpneumothoraxorapleuraleffusion.Itis
morecommoninpatientwithdiabetesandinpatientswithtensionorlarger
sizepneumothoracesandinpatientswithlargepleuraleffusions. [12]

PeriproceduralCare
Anesthesia
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Seethelistbelow:
Systemicanalgesiashouldbeusedinallconsciouspatients,unless
contraindicated.
Contraindicationstouseofsystemicanalgesiacanincludeunstablevital
signsandpatientinextremis.
Proceduralsedationandanalgesiashouldbeconsidered,unless
contraindicated.Formoreinformation,seeProceduralSedation.
LocalanesthesiaisdescribedintheTechniquesection.Formore
information,seeLocalAnestheticAgents,InfiltrativeAdministration.

ContributorInformationandDisclosures
Author
GilZShlamovitz,MD,FACEPAssociateProfessorofClinicalEmergencyMedicine,KeckSchoolofMedicine
oftheUniversityofSouthernCaliforniaChiefMedicalInformationOfficer,KeckMedicineofUSC
GilZShlamovitz,MD,FACEPisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergency
Physicians,AmericanMedicalInformaticsAssociation
Disclosure:Nothingtodisclose.
SpecialtyEditorBoard
MaryLWindle,PharmDAdjunctAssociateProfessor,UniversityofNebraskaMedicalCenterCollegeof
PharmacyEditorinChief,MedscapeDrugReference
Disclosure:Nothingtodisclose.
LuisMLovato,MDAssociateClinicalProfessor,UniversityofCalifornia,LosAngeles,DavidGeffenSchoolof
MedicineDirectorofCriticalCare,DepartmentofEmergencyMedicine,OliveViewUCLAMedicalCenter
LuisMLovato,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanCollegeof
EmergencyPhysicians,SocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
ChiefEditor
RylandPByrd,Jr,MDProfessorofMedicine,DivisionofPulmonaryDiseaseandCriticalCareMedicine,
JamesHQuillenCollegeofMedicine,EastTennesseeStateUniversity
RylandPByrd,Jr,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofChestPhysicians,
AmericanThoracicSociety
Disclosure:Nothingtodisclose.
AdditionalContributors
LuisMLovato,MDAssociateClinicalProfessor,UniversityofCalifornia,LosAngeles,DavidGeffenSchoolof
MedicineDirectorofCriticalCare,DepartmentofEmergencyMedicine,OliveViewUCLAMedicalCenter
LuisMLovato,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanCollegeof
EmergencyPhysicians,SocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
Acknowledgements
TheauthorsandeditorsofMedscapeReferencegratefullyacknowledgetheassistanceofLarsGrimmwiththe
literaturereviewandreferencingforthisarticle.

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