Overview
Definition:
Chest tube placement, also known as tube thoracostomy or pleural drainage, is a procedure to insert a tube into the pleural space to drain air, fluid, or pus
For hemothorax, it specifically aims to remove blood from the pleural cavity.
Epidemiology:
Hemothorax occurs in a significant proportion of patients with chest trauma, estimated to be between 25-50% of significant thoracic injuries
Spontaneous hemothorax is less common, occurring in approximately 1-2% of patients presenting with pleuritic chest pain and hemoptysis.
Clinical Significance:
Prompt and effective drainage of hemothorax is crucial to prevent complications such as respiratory compromise, fibrothorax, infection (empyema), and persistent hemothorax requiring further intervention
It is a fundamental skill for surgical residents preparing for DNB and NEET SS examinations.
Indications
Indications:
Hemodynamic instability in the setting of chest trauma with evidence of hemothorax on imaging
Significant hemothorax (>300-500 mL of blood initially seen on imaging or with ongoing hemoptysis)
Persistent hemothorax on serial imaging
Spontaneous hemothorax with significant blood loss or respiratory compromise
Postoperative hemothorax following thoracic surgery.
Contraindications:
Absolute contraindications are rare but include complete lung collapse preventing re-expansion, uncontrolled coagulopathy, and severe bullous lung disease at the insertion site
Relative contraindications include severe emphysema, pleural adhesions, and extensive scarring at the insertion site.
Timing Of Intervention:
Urgent intervention is required for unstable patients
For stable patients with significant hemothorax, chest tube placement should be performed promptly to facilitate lung re-expansion and prevent complications.
Preoperative Preparation
Patient Assessment:
Thorough assessment of vital signs, hemodynamic stability, respiratory status, and coagulation profile
Review of imaging (chest X-ray, CT scan) to delineate the extent of hemothorax and identify associated injuries.
Informed Consent:
Obtain informed consent from the patient or their representative, explaining the procedure, risks, benefits, and alternatives.
Equipment Gathering:
Sterile chest tube kit (including chest tube, trocar, scalpel, forceps, clamps, drainage system, sutures, sterile dressing)
Local anesthetic agent (e.g., lidocaine 1% or 2%)
Syringe and needle for local anesthesia
Antibiotic prophylaxis (e.g., second-generation cephalosporin) as per hospital protocol.
Patient Positioning:
The patient is typically positioned supine or in a lateral decubitus position with the affected side up
The arm on the affected side is usually abducted and placed above the head to widen the intercostal spaces.
Procedure Steps
Site Selection:
The insertion site is typically the 4th or 5th intercostal space in the mid-axillary line (the "triangle of safety")
This avoids injury to intercostal vessels and nerves which are located inferior to the rib
Palpate the superior border of the lower rib to identify the correct space.
Skin Preparation And Anesthesia:
Sterile preparation of the insertion site with antiseptic solution
Infiltration of local anesthetic into the skin, subcutaneous tissue, and periosteum of the rib.
Incision And Dissection:
A small skin incision (approximately 2-3 cm) is made over the selected intercostal space
Blunt dissection with a hemostat or clamp is then used to spread through the subcutaneous tissue and intercostal muscles, creating a path towards the pleura.
Pleural Entry And Tube Insertion:
Once the parietal pleura is reached, a finger is used to palpate for the pleural space and confirm entry, checking for adhesions or masses
The chest tube is then advanced into the pleural space under direct vision or digital guidance, directed posteriorly and superiorly to ensure proper drainage and avoid kinking
The tube should be advanced sufficiently to drain the entire hemothorax, typically to the apex.
Securing And Connection:
The chest tube is secured to the skin with sutures
A sterile dressing is applied
The tube is then connected to a closed chest drainage system, ensuring an airtight seal
The drainage system is placed below the level of the chest tube insertion site to facilitate gravity drainage.
Postoperative Care
Monitoring:
Continuous monitoring of vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation)
Regular assessment of chest tube output (amount, color, consistency)
Auscultation of lung sounds to assess for re-expansion and absence of air leaks.
Pain Management:
Adequate analgesia is essential, often requiring multimodal approaches including oral or intravenous analgesics and intercostal nerve blocks if necessary
Pain control improves patient comfort and facilitates deep breathing and ambulation.
Drainage System Management:
Ensuring patency of the drainage system, checking for kinks, air leaks, and excessive bubbling (indicative of air leak from the lung)
Milking or stripping of the tube may be performed cautiously if there is significant clot or debris, but this should be done with caution to avoid damaging the tube or pleura.
Chest Tube Removal:
Chest tubes are typically removed when drainage is minimal (<100-200 mL per 24 hours), there are no air leaks, and the lung is fully expanded on chest X-ray
A clamp trial may precede removal to ensure the lung remains inflated without the tube.
Complications
Early Complications:
Bleeding from intercostal vessels or lung parenchyma
Injury to intrathoracic organs (lung, heart, diaphragm, great vessels)
Malposition of the tube
Subcutaneous emphysema
Vasovagal syncope
Pain
Infection (pleural space infection, empyema)
Re-expansion pulmonary edema.
Late Complications:
Chronic pain at the insertion site
Rib fracture during insertion
Persistent pleural space infection
Fibrothorax (thickening of the pleura leading to lung restriction)
Bronchopleural fistula
Migration or dislodgement of the tube.
Prevention Strategies:
Adherence to sterile technique
Meticulous anatomical landmark identification
Careful insertion technique to avoid inadvertent injury
Proper tube selection and placement
Adequate pain management
Appropriate antibiotic prophylaxis
Prompt recognition and management of any complications.
Key Points
Exam Focus:
The "triangle of safety" for chest tube insertion
Indications for chest tube drainage in hemothorax
Management of significant hemothorax
Complications of chest tube placement
Management of air leaks and heavy drainage.
Clinical Pearls:
Always confirm tube placement with a chest X-ray post-procedure
Consider a CT scan for complex trauma or suspected retained hemothorax
Continuous suction may be applied if lung re-expansion is suboptimal
Pain control is paramount for patient recovery and lung re-expansion.
Common Mistakes:
Incorrect site selection leading to neurovascular bundle injury
Blind insertion without adequate blunt dissection
Over-advancing or under-advancing the tube
Failure to secure the tube adequately
Inadequate management of drainage system leading to complications.