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Chest Tube Placement – Brief Explanation and Uses

A chest tube placement is used to extract (drain) any substance that has penetrated the pleural cavity to relieve the pressure and help re-expand and inflate the lungs back up again before the lung collapse worsens.

“A chest tube is a flexible plastic tube that is inserted through the chest wall and into the pleural space or mediastinum. It is used to remove air in the case of pneumothorax or fluid such as in the case of pleural effusion, blood, chyle, or pus when empyema occurs from the intrathoracic space. It is also known as a Bülau drain or an intercostal catheter. Insertion of chest tubes is widely performed by radiologists, pulmonary physicians and thoracic surgeons. Large catheters or small catheters are used based on each situation that the medical doctor encounters.”1

It is inserted and placed to help recover lungs’ normal function and expansion when there is a respiratory difficulty or lungs failure, to prevent the lungs from collapsing. Most commonly put after a trauma or a life-threatening respiratory diagnose when air, fluids or gas penetrate the lungs and cause a pneumothorax. A chest tube is placed after a pneumothorax, or if there is a diagnosed situation that compromises lungs normal function.

“Descriptions of procedural drainage of the pleural space date back to the times of Hippocrates. Despite different techniques and devices used throughout the history, the basic principles did not change. Today, tube thoracostomy (TT) placement remains among the most commonly performed procedures, from bedside to operating room, from life-threatening emergencies to postoperative chest drainage in elective surgery. In the injured patient, TT may be lifesaving and facilitates evacuation (and monitoring) of hemothorax, prevents the development of tension pneumothorax while promoting lung reexpansion, tamponades low pressure pulmonary bleeding, and improves respiratory function. In the surgical patient, chest tubes facilitate postoperative recovery. Patients with malignancies may benefit from symptomatic relief brought about by drainage of persistent, large pleural effusions. Despite potential benefits of TT drainage, many possible complications exist.”2

This medical procedure needs to be done to help re-inflate the collapsed lung when the parietal pleura is damaged or injured, and the lung is compressed not allowing its natural expansion. This situation compromises normal breathing (inhaling and exhaling) function, and if not practiced it can become critical and life-threatening.

The chest tube placement is also known as thoracostomy or intercostal drain.

  • Helps relief the pressure after a pneumothorax has been detected (diagnosed) to support the collapsed lung re-inflate again before it gets worse.
  • It also allows and helps recover the full re-expansion of the lung and improve oxygen transfer.

If a pneumothorax worsens the oxygen transfer to the bloodstream and cells will be compromised

The chest tube is placed to

  • Extract fluids, air, gas, blood or pus accumulation in the space between the visceral pleura and the parietal pleura (pleural space). Visceral Pleura is the one that covers the lungs surface. Parietal Pleuralis the one that covers the pleural cavity surface. (The one between the pleural space and the chest cavity).
  • Inject medications that artificially help remove the pleural space: inflating both the parietal and visceral pleura making them stick together and remove the space between them (the pleural space) to prevent regular fluid accumulation. This chest tube placement use and the procedure is called Pleurodesis.

“Thoracostomy has evolved as a primary treatment for evacuation of air or fluid in the pleural space from a myriad of causes. Air within the pleural space is one of the most common reasons for a chest tube. Within the context of pneumothoraces, indications include:

  • Large (> 25% or apex to copula distance > 3 cm) primary spontaneous pneumothorax; small pneumothorax in this patient population with no underlying lung disease can usually be managed with observation alone.
  • Mechanically ventilated patients with pneumothorax or effusions to decrease the work of breathing and help the patient wean off the ventilator.
  • Secondary spontaneous pneumothorax. Patients with underlying lung disease (cystic fibrosis, interstitial lung disease, emphysema, etc.) will benefit from thoracostomy. They usually have pronounced symptoms and a high recurrence rate with no intervention. There have been reports of increased mortality in those patients where clinical observation is done for small pneumothoraces. Large (> 25% or apex to cupula distance > 3 cm) pneumothorax requires chest tube placement.
  • Hemodynamically unstable patient
  • Recurrent or persistent pneumothorax
  • Tension pneumothorax requires needle decompression followed by an ipsilateral chest tube
  • Pneumothorax related to trauma.

Because of the risk of a tension pneumothorax, a chest tube should be considered for all patients with a penetrating chest injury if positive pressure ventilation will be used or if they have delayed access to definitive care.”3

Also used to inject fibrinolytic agents, deoxyribonuclease (DNase) in the pleural space to dilute (thin) thick substances and help improve the drainage of the fluid. Can be practiced to drain pleural infections.

The chest tube placement is a minimally invasive surgical lifesaving procedure that can be performed by a doctor at a healthcare facility emergency or operating room or by a critical care paramedic at an accident site.

A small insertion is done under the armpit between the 4th and 5th rib space, on the side where the collapsed lung is suspected or diagnosed (after obtaining the x-ray image). Then the chest tube is inserted and placed following all the necessary antiseptic procedure. After it is set correctly the outside side of the tube is connected to the draining device to start the substance extraction process.

  • To drain air, the chest tube is placed towards the upper lung space area.
  • To remove fluid, the chest tube is situated at the lung base.

 “Indications for chest tube placement include: (a) pneumothorax; (b) penetrating chest trauma; (c) severe blunt chest trauma; (d) hemothorax; (e) chylothorax; (f) symptomatic pleural effusion; (g) bronchopleural fistula; (h) chemical pleurodesis for benign and malignant conditions; (i) postoperative use in thoracic/cardiac surgery; and (j) complicated parapneumonic effusion or empyema. In addition, a number of relative indications for TT placement exist. Due to the limited scope of this article, the reader is referred elsewhere for a complete list. Contraindications to thoracostomy placement have to be considered in the context of the overall risk-benefit assessment. For example, there are no contraindications to TT placement for tension pneumothorax. However, previous history of pleurodesis or lung transplantation may preclude “blind” chest tube placement and trigger the performance of image-guided TT procedure. Patients with extensive pulmonary blebs also have a relative contraindication to TT placement because of the risk of bronchial fistula formation. Elective or semi-elective TT placement should be avoided in patients with clinically significant coagulopathy and consideration should be given to normalization of coagulation parameters prior to commencing with the procedure.”4

A chest tube placement is needed when the following respiratory complications or problems are diagnosed:

Pneumothorax

When gas or air penetrate the pleural space and lung collapses due to a trauma, a car accident, a chest stroke during a sport, lung disease or a surgical complication, also during air pressure changing experiences like scuba diving or climbing, when blebs or small sacks of air are formed in the lungs tissue causing ruptures letting air enter the pleural cavity causing the collapse.

Hemothorax

When blood penetrates the pleural space compromising lungs function due to a stab wound, gunshot, significant impact, a sharp object trauma or chest surgery complication.

Pleural Effusion or Empyema

When there is fluid or pus accumulation in the pleural space due to pulmonary infection, pneumonia, bronchitis, viral infection (HIV), chronic obstructive pulmonary disease (COPD), asthma, pulmonary embolism, or lung cancer.

Valve artificial ventilation failure

When air keeps on pumping inside the pleural space (between the lungs and the chest wall) but it doesn’t come out, due to a valve failure. Continually inflating putting more pressure and expanding the area.

This Pneumothorax pressure needs to be relieved quickly before if pushes the trachea and heart and collapses the other lung, to help prevent a fatal situation.

The chest tube placement or thoracostomy is an emergency practiced procedure in most cases because it can lead to a life-threatening situation if not done in time.

Contraindications for tube thoracostomy

“There are relatively few contraindications for chest tube placement. The only absolute contraindication being an adherent lung to the chest wall throughout the entire hemithorax. However, this stipulation is negated in a clinically unstable patient with a pneumothorax or hemothorax. In these situations, chest tubes are done empirically as the full extent of the air or fluid collection cannot be properly assessed because of resuscitative efforts.

Relative contraindications include coagulopathy, increased risk of bleeding and infection overlying the insertion site. Risk of bleeding can be addressed with platelets and clotting factor replacement relative to the deficit. Replacement is encouraged when platelets are less than 50,000, prothrombin time/partial thromboplastin time (PT/PTT), or international normalized ratio (INR) are greater than twice the upper limit of normal. Overlying cellulitis or zoster infection should be avoided by choosing another puncture site.”5

Complications

“Serious complications during placement of small-bore tunneled indwelling pleural catheters are rare. On multicenter review, the most common complications of small-bore pleural drainage catheter placement include empyema (3%), cellulitis (3%), catheter malfunction (4%), pneumothorax (6%), and catheter dislodgement (2%). During treatment of malignant pleural effusions, tract metastases have been reported (4%). More catheters were removed due to achievement of spontaneous pleurodesis (47%) than to complications (9%). Serious complications including significant postprocedure bleeding, extrapleural catheter placement, and hepatic injury have been reported in nonimage-guided series.”6

References:

(1) Chest drainage systems in use. Zisis, C., Tsirgogianni, K., Lazaridis, G., Lampaki, S., Baka, S., Mpoukovinas, L., Karavasilis, V., Kioumis, L., Pitsiou, G., Katsikogiannis, N., Tsakiridis, K., Rapti, A., Trakada, G., Karapantzos, I., Karapantzou, C., Zissimopoulos, A., Zarogoulidis, K. & Zarogoulidis, P. Annals Of Translational Medicine. 2015. http://atm.amegroups.com/article/view/5796/6572

(2) Tube thoracostomy; chest tube implantation and follow up. Kuhajda, I., Zarogoulidis, K., Kougioumtzi, K., Huang, H., Li, Q., Dryllis, G., Kioumis, L., Pitsiou, G., Machairiotis, N., Katsikogiannis, N., Papaiwannou, A., Lampaki, S., Papaiwannou, A., Zaric, B., Branislav, P., Porpodis, K. & Zarogoulidis, P. Journal Of Thoracic Disease. 2014. http://jtd.amegroups.com/article/view/3133/3681

(3, 5, 6) Tube Thoracostomy: A Review for the Interventional Radiologist. Hogg, J.R., Caccavale, M., Gillen, B., McKenzie, G., Vlaminck, J., Fleming, C.J., Stockland, A. &  Friese, J.L. Seminars in Interventional Radiology. 2011.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3140253/

(4) Thoracostomy tubes: A comprehensive review of complications and related topics. Michael Kwiatt, M., Tarbox, A., Seamon, M.J., Swaroop, M., Cipolla, J., Allen, C., Hallenbeck, S., Davido, H.T., Lindsey, D.E., Doraiswamy, V.A., Galwankar, S., Tulman, D., Latchana, N., Papadimos, T.J., Cook, C.H. & Stawicki, S.P. International Journal Of Critical Illness & Injury Science. 2014. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4093965/

María Laura Márquez
13 October, 2018

Written by

María Laura Márquez, general doctor graduated from The University of Oriente in 2018, Venezuela. My interests in the world of medicine and science, is focused on surgery and its greatest advances. Nowadays I practice my...read more:

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