Tube thoracostomy

A tube thoracostomy is a procedure by which a tube is inserted into the chest cavity in order to evacuate air or fluid.

INDICATIONS

Traumatic pneumothorax (PTX)

Moderate-to-large PTX

Respiratory symptoms, irrespective of the size of the PTX

Recurring PTX after removal of initial chest tube

Patients requiring ventilator support

Patients requiring general anaesthesia

Haemothorax (HTX) associated with PTX

Bilateral PTX of any size

Tension pneumothorax

Prophylactically when airlifting patients with chest trauma (to prevent spontaneous PTX due to high altitude)


CONTRAINDICATIONS
(relative)

Previous thoracotomy

Previous pneumonectomy

Coagulation disorders

.

DISCUSSION

A pneumothorax (PTX), particularly a tension PTX, is a potentially life-threatening condition. Air, or sometimes fluid (as in the case of a haemothorax) invades the pleural cavity - the empty space surrounding the heart and lungs - causing positive intrapleural pressure. The positive pressure upsets the normal balance of things in the pleural cavity, and compresses the heart and lungs. This compression can preven the heart and lungs from functioning, and can lead to death in very short order. Therefore, the contraindications must be balanced against the substantial potential risk of not performing the procedure. Tube thoracostomy is generally performed after emergent needle decompression (needle thoracostomy), and is the definitive management of (haemo-)pneumothoraces.

In order to perform the procedure, sedate the patient, if conscious. Locate the fifth or sixth intercostal space (i.e. space between the 5^th and 6^th or 6^th and 7^th ribs) along the linea axillaris media, an imaginary line passing through the middle of the axilla. Prepare the incision site with povidone iodine solution. Make an incision of 3cm length over the 5^th or 6^th rib along the linea axillaris media.After using a curved haemostat to dissect through the soft tissue all the way down to the rib, push the haemostat over the superior part of the rib - avoiding contact with the intercostal neurovascular bundle that is right underneath the inferior aspect of the next higher rib - and puncture the intercostal muscles and parietal pleura. Hold the puncture open by placing your finger alongside the haemostat while removing the haemostat. Keep your finger in place to facilitate insertion of the chest tube. A clamp may be used to steady the tube at the proximal (closest to the insertion point) end. If the tube has been properly placed, it will fog up as it fills with the air from the pleural cavity. Now that the tube has been inserted into the pleural cavity, it must be hooked up to an external underwater seal and suction device (e.g. Pleur-Evac ®). After connecting to external suction, the tube must be sutured and taped to hold it in place. Then, confirm lung re-expansion radiographically.

Complications arising from tube thoracostomy are generally related to improper insertion or placement, and include damage to the intercostal neurovascular bundles or the lung parenchyma itself. These risks are increased by the use of a trocar.