Background
A thoracostomy tube is a hollow plastic tube or catheter that is used to drain air, fluid, pus, or blood from the intrathoracic space ( Fig. 15.1 ). The word “thoracostomy” combines the prefix “thoraco” meaning “chest wall” and the suffix “stomy” meaning “opening.” Thoracostomy tube may sometimes be referred to as a chest tube (the term that will be used throughout this chapter), intrapleural drain, or pigtail ( Fig. 15.2 ). The procedure to place the chest tube is called tube thoracostomy.
How to Use It
Indications for a chest tube include pneumothorax, hemothorax, and pleural effusions. Primary spontaneous pneumothorax occurs without predisposing factors or significant lung disease, and the male sex and smoking are risk factors. Iatrogenic pneumothorax occurs most commonly due to central line placement. Traumatic pneumothorax occurs with blunt or penetrating trauma to the chest. Pneumothorax after lung resection may develop from a persistent air leak or a bronchopleural fistula that does not resolve. Tension pneumothorax, the accumulation of air in the chest under positive pressure, is a life-threatening condition that leads to hemodynamic instability and requires immediate decompression by a needle or a chest tube. Hemothorax results from blunt or penetrating trauma to the chest wall or after a fall. It can also develop following cardiac events, thoracic surgery, or aortic conditions. Using Light’s criteria, pleural effusions are defined as exudate or transudate according to pleural fluid protein and lactate dehydrogenase (LDH) values. If the pleural fluid/serum protein ratio is greater than 0.5, the pleural fluid/serum LDH ratio is greater than 0.6, or the pleural fluid LDH value is greater than two-thirds the upper limit of the normal serum LDH, the fluid is exudative indicating infection, inflammation, or malignancy. Some medications such as methotrexate, bromocriptine, nitrofurantoin, and amiodarone may lead to an exudative pleural effusion. The most common causes of transudative pleural effusion include congestive heart failure and cirrhosis with ascites. In the case of recurrent effusions, chest tubes may be used to instill sclerosing agents into the pleural space to induce pleurodesis. When adhesions are present in the pleural space, ultrasound guidance is the preferred method for tube insertion.
How It Is Done
Pulmonologists, intensivists, emergency room physicians, interventional radiologists, or general, trauma, or thoracic surgeons can insert a chest tube. Most chest tube insertions are completed at bedside. The patient’s arm should be placed behind the head to expose the axillary area. The area for insertion is determined by locating the fourth to fifth intercostal space in the anterior axillary line at the level of the nipple. This is referred to as the triangle of safety, which is the triangle between the apex of the axilla, the anterior margin of the latissimus dorsi, and lateral margin of the pectoralis major at the level of the nipple. The skin and the subcutaneous tissue at the insertion site should be anesthetized by locally injecting 10–20 mL of 1% lidocaine solution. An incision of 1.5 to 2.0 cm in length is made parallel to the rib, and a Kelly clamp is used to cut through the intercostal muscles to the pleural space. The tube is then directed vertically in case for pneumothorax or basally for effusion. Conscious sedation (benzodiazepines [e.g., midazolam] and analgesics [e.g., morphine or fentanyl]) can be used in nonemergent cases according to physician preference or patient comfort level.
There are two methods to place chest tubes: the dissecting method places larger-bore (20-French or larger) tubes and the Seldinger method uses smaller (14-French or smaller) tubes and is done under ultrasound guidance. The dissecting method is usually performed at bedside or in the operating room (OR), and the Seldinger method can be performed at bedside or in a radiology suite. The size of the tube usually depends on the indication for the procedure (pneumothorax vs. effusion), the effusion characteristics (transudate vs. exudate), and patient condition. Most hospitals have presterilized chest tube insertion trays. The trays contain a scalpel, dissecting instruments, syringes, needles, sutures, and tubes of different sizes. Following lung resection or other thoracic procedures, a chest tube that was placed in the OR may remain with the patient when being transferred to the medical ward. For a pneumothorax, the tube can be removed once bubbling (air leak) ceases and the lung is fully expanded on chest X-ray. A pleural drainage system attaches to the tube once it is placed ( Fig. 15.3 ). For pleural effusion, the drainage volume should be less than 200 mL in 24 hours to consider removal of the tube. Relative contraindications to chest tube placement include use of anticoagulant medications, coagulopathy, bleeding disorders, diaphragmatic hernia, or overlying infection. Complications of chest tube placement include hemorrhage, infection, or inadvertent laceration of the liver or spleen. Long-term complications include tube clogging or persistent air leak. ,
