Overview
Definition:
Chest tube placement, also known as tube thoracostomy or chest drain insertion, is a procedure to insert a tube into the pleural space to drain air, fluid, or pus
It is the definitive management for a pneumothorax, which is the presence of air in the pleural cavity leading to lung collapse.
Epidemiology:
Pneumothorax incidence varies, with spontaneous pneumothorax being more common in tall, thin young men (primary) or individuals with underlying lung disease like COPD or emphysema (secondary)
Traumatic pneumothorax can occur from blunt or penetrating chest trauma or iatrogenically from medical procedures
The incidence of primary spontaneous pneumothorax is approximately 7-18 per 100,000 men and 2-6 per 100,000 women per year.
Clinical Significance:
Untreated pneumothorax can lead to respiratory distress, hypoxemia, and in tension pneumothorax, hemodynamic compromise and death
Prompt and accurate chest tube placement is critical for lung re-expansion, symptom relief, and preventing life-threatening complications, making it a fundamental skill for surgical residents.
Clinical Presentation
Symptoms:
Sudden onset of pleuritic chest pain
Dyspnea, often sudden and progressive
Feeling of tightness in the chest
In severe cases, tachypnea, tachycardia, cyanosis, and anxiety.
Signs:
Decreased or absent breath sounds on the affected side
Hyperresonance to percussion
Tracheal deviation away from the affected side (in tension pneumothorax)
Subcutaneous emphysema
Hypotension and shock in tension pneumothorax.
Diagnostic Criteria:
Diagnosis is primarily clinical, confirmed by imaging
Criteria include characteristic symptoms and signs coupled with radiographic evidence of air in the pleural space, with or without lung collapse
Tension pneumothorax is a clinical diagnosis based on hemodynamic instability and absent breath sounds with tracheal deviation, even before imaging.
Diagnostic Approach
History Taking:
Detailed history of onset and character of chest pain and dyspnea
Prior history of pneumothorax, lung disease (COPD, asthma, cystic fibrosis), trauma, or thoracic surgery
History of recent medical procedures (e.g., central line insertion, thoracentesis, intubation)
Risk factors for spontaneous pneumothorax (smoking, Marfan syndrome).
Physical Examination:
Assess for respiratory distress, vital signs (BP, HR, RR, SpO2)
Inspect chest wall for symmetry of movement and signs of trauma
Palpate for tactile fremitus (decreased) and subcutaneous emphysema
Percuss for hyperresonance
Auscultate for decreased or absent breath sounds
Assess for tracheal deviation.
Investigations:
Chest X-ray (PA and lateral views) is the initial investigation of choice to confirm pneumothorax and assess the extent of lung collapse
Lateral decubitus views can be helpful for small pneumothoraces
CT scan of the chest is more sensitive for detecting small pneumothoraces, identifying underlying lung pathology (bullae), and evaluating for traumatic injuries
Arterial blood gas (ABG) analysis to assess oxygenation and ventilation status.
Differential Diagnosis:
Pulmonary embolism
Acute myocardial infarction
Pneumonia
Pleurisy
Rib fracture with associated injury
Musculoskeletal chest pain
Pulmonary contusion.
Management
Initial Management:
Immediate assessment of ABCs (Airway, Breathing, Circulation)
Supplemental oxygen
Large-bore intravenous access
Continuous cardiorespiratory monitoring
Pain control with analgesics
For suspected tension pneumothorax: immediate needle decompression followed by chest tube insertion.
Chest Tube Insertion Procedure:
Indications include symptomatic pneumothorax, >2 cm lung collapse on CXR, or any pneumothorax in a mechanically ventilated patient
A small bore (10-14 Fr) or large bore (20-28 Fr) chest tube may be used depending on indications
Common sites for insertion are the 2nd intercostal space in the midclavicular line (for air drainage) or the 4th-5th intercostal space in the anterior or mid-axillary line (for fluid drainage)..
Surgical Management:
Surgical intervention (VATS or thoracotomy) may be indicated for recurrent pneumothorax, persistent air leak, failure of chest tube drainage, or hemothorax
Procedures include pleurodesis (chemical or mechanical) to obliterate the pleural space and prevent recurrence, and resection of blebs or bullae.
Postoperative Care:
Chest tube management: ensure patency, monitor drainage volume and character, assess for air leak
Chest X-ray to confirm lung re-expansion and tube position
Pain management
Early mobilization
Respiratory physiotherapy
Monitor for complications
Chest tube removal when air leak has resolved and lung is fully re-expanded.
Complications
Early Complications:
Bleeding from intercostal vessels or lung parenchyma
Injury to lung, diaphragm, or abdominal organs
Pain at the insertion site
Infection (empyema)
Malposition of the tube
Persistent air leak
Re-expansion pulmonary edema.
Late Complications:
Chronic pain
Bronchopleural fistula
Scarring and pleural thickening
Recurrent pneumothorax if pleurodesis is not effective
Migration or obstruction of the tube.
Prevention Strategies:
Strict adherence to sterile technique during insertion
Meticulous dissection through layers to avoid injuring vital structures
Careful anatomical landmark identification
Use of ultrasound guidance for optimal placement
Adequate pain control to facilitate deep breathing and mobilization
Close monitoring of chest tube function and drainage.
Prognosis
Factors Affecting Prognosis:
Underlying lung health
Size and type of pneumothorax
Presence of complications
Promptness of diagnosis and treatment
Patient comorbidities
Success of pleurodesis in preventing recurrence.
Outcomes:
Most small, asymptomatic pneumothoraces may resolve spontaneously
Symptomatic pneumothoraces treated with chest tube drainage generally have good outcomes with complete lung re-expansion and symptom relief
Recurrence rates for spontaneous pneumothorax can be significant (up to 30-50% without pleurodesis), necessitating consideration of surgical management for some patients.
Follow Up:
Follow-up chest X-rays are typically performed after chest tube removal to ensure continued lung expansion
Patients with a history of pneumothorax, especially spontaneous pneumothorax, should be advised on risk factors (e.g., smoking cessation) and educated about the symptoms of recurrence
Surgical follow-up is tailored to the procedure performed.
Key Points
Exam Focus:
Indications for chest tube insertion
Anatomical landmarks for insertion (2nd ICS MCL vs
4th-5th ICS AAL/MAL)
Differentiate needle decompression vs
chest tube
Complications of chest tube placement
Management of persistent air leak and recurrent pneumothorax.
Clinical Pearls:
Always consider tension pneumothorax in hypotensive, dyspneic patients with absent breath sounds
immediate needle decompression is life-saving
Ultrasound can aid in identifying the pleural line and guiding insertion
Secure the chest tube meticulously to prevent dislodgement
Educate patients on smoking cessation to reduce recurrence risk.
Common Mistakes:
Incorrectly identifying anatomical landmarks leading to organ injury or ineffective drainage
Failure to recognize tension pneumothorax promptly
Inadequate sealing of the insertion site leading to subcutaneous emphysema or infection
Dislodgement of the chest tube
Overlooking persistent air leak or failure of lung re-expansion, delaying appropriate intervention.