Chest Tube Placement

Introduction:

Chest trauma in modern warfare occurs in 7-15% of cases [5-6]. Injuries sustained to the thorax require immediate attention as approximately one in six injuries carry an immediate mortality risk due to cardiac tamponade, massive hemothorax, or lung parenchymal or airway injury resulting in massive air leak [6]. The most common indications for chest tube placement are pneumothorax or hemothorax; however, important to note, there are no absolute contraindications, particularly given the life-threatening scenarios previously described [3, 7].

Initial Evaluation and Diagnosis:

Chest Tube Placement in the Primary Survey

Thoracic trauma affects oxygenation, ventilation, and maintenance of circulation. Immediate evaluation and correction of irregularities to the primary survey is critical to chest trauma [2]. Keen attention to the physical exam can quickly diagnosis pneumothorax, tension pneumothorax, or massive hemothorax requiring immediate drainage. Indications for immediate chest tube placement commonly includes:

Breathing: Failure to auscultate bilateral breath sounds after blunt or penetrating trauma is an indication for immediate tube thoracostomy. Even with breath sounds present, hypoxia not improved with oxygen is also a potential indication for chest tube placement

Circulation: Hypotension or distended neck veins are signs of compromised circulation that may be due to an injury requiring chest tube placement. Intra-thoracic bleeding can cause hypotension from hemorrhage and tension pneumothorax can cause hypotension from compromised cardiac filling. In either case, prompt chest decompression is paramount and treatment should precede definitive diagnosis.

Immediate threats to life include a tension pneumothorax, open pneumothorax, massive hemothorax or flail chest, all of which require finger, needle, or tube thoracostomy. Tension pneumothorax can be seen by distended neck veins, oxygen desaturation or hypotension. Massive hemothorax can cause hypotension or desaturation. Open pneumothorax or flail chest requires first a closure of the wound with a one-way value occlusive dressing and placement of a chest tube.

Chest Tube Placement after Adjuncts to the Primary Survey:

Adjuncts to the primary survey include chest plain film (CXR) and focused ultrasonography for the assessment of trauma (FAST) and can readily identify indications for immediate chest tube placement [8]. CXR should be taken as upright as possible as >1L of blood may be missed on a supine film [9]. If available, both CXR and FAST should be performed in all thoracic trauma patients. Furthermore, the astute trauma surgeon must always consider the 30-80% risk of concomitant hemo- and/or pneumothorax in blunt trauma patients with rib fractures [10-11].

Chest Tube Placement in the Secondary Survey:

Palpable crepitus is a major finding on secondary survey and is an indication for unilateral tube thoracostomy. Additionally, any changes in the patient’s status during secondary survey warrants revisiting the primary survey and may require tube thoracostomy placement.

Procedure:

The goal of the procedure is to equilibrate the pressure between the thorax and the atmosphere and allow for drainage of inappropriate pleural cavity contents. Thus, efforts such as finger thoracostomy (surgeon uses their digit to dissect into the pleural space) or needle thoracostomy (a wide gauge needle is used to puncture through the chest wall into the pleural space) can quickly temporize a life-threatening situation. However, always the goal of any thoracostomy should be placement of a formal tube or pigtail catheter in a trauma scenario.

The patient’s ipsilateral arm should be abducted and extended over their head exposing the “safe triangle” for access into the chest. This is bordered by the latissimus dorsi anteriorly, the pectoralis major muscle laterally, and a line superior to the horizontal level of the nipple. For easier anatomic assessment, most trauma chest tubes are placed just superior to the nipple or inframammary crease in women, in the mid- to anterior- axillary line approximately corresponding to the 4^th or 5^th intercostal space. If time and resources allow, this area should be prepped and draped in sterile fashion. In addition, local anesthetic infiltration on a long, 20-gauge needle can be used to confirm rib landmarks and direction into pleural space while aspirating.

In the trauma setting, a generous 4-5cm incision should be made parallel and over the rib inferior to the intercostal space the surgeon plans to enter. As a principle for quick and seamless insertion, err on the side of a wider incision. Next, a medium to large curved, blunt tip surgical clamp (Kelly clamp) should be used to dissect through the subcutaneous fat and intercostal muscles. Dissection should proceed in the direction immediately superior to the rib to avoid injury to the intercostal neurovascular bundles which run below the ribs. To enter the pleural cavity, the surgeon should push the closed instrument in a controlled fashion through the pleura immediately superior to the palpated rib. The clamp tips should be opened completely in two different vectors in order to spread open the pleura and subcutaneous tissues. Upon entering the pleural space, one may hear a rush of air or observe a gush of blood indicating likelihood of proper cavity access.

At this point, the surgeon should perform a finger thoracostomy. However, they must be vigilant of potential rib fractures or imbedded shrapnel that can cause injury. A proper finger thoracostomy includes a hooked index finger inserted completely into the pleural space and subsequent rotation 360 degrees to further the dissection and ensure no lung parenchyma is trapped against the chest wall.

Finally, using either the same wide clamp in the original dissection or your finger, guide the chest tube into the pleural space. A second clamp on the distal aspect of the tube will help ensure no hemorrhage spills onto the floor or colleagues and no additional atmospheric air travels back into the chest with a subsequent breath. The tube should be guided either to the lung apex or base depending on the suspected pathology. To the best of the surgeon’s ability, the tube entering the pleural space should be confirmed via palpation to avoid potential placement of a subcutaneous tube. Once in place, a colleague should sterilely, if possible, connect the tube to a drainage container (discussed more in next section). Meanwhile, the surgeon should use a non-absorbable, thick suture in a horizontal mattress or interrupted technique to close the wound around the tube and secure the tube to the skin. For slightly larger wounds not adequately closed by suture, Xeroform or Vaseline coated gauze can help act as an impenetrable barrier to prevent air leaking around the tube.

Ongoing Management and Complications:

Following placement, it is strongly recommended to obtain a CXR either immediately or when clinically safe after the patient is stabilized. Complications following chest tube placement occur at a rate between 6 and 37% and the emergency setting contributed to the majority and include tube malposition, intercostal or visceral bleeding, visceral injury, transdiaphragmatic insertion, or subacute empyema development [2-3, 14-15]. In certain circumstances, placement of a second tube may be necessary.

Drainage containers use a water-filled chamber to act as one-way valve, permitting egress of air and fluid from the chest cavity into the drainage container. The container may be hooked to suction if available to assist in active drainage. Modern chest tube water-seal containers include additional chambers connected in series to allow for chest fluid measurement and visualization, in addition to suction control for prevention of excessive negative pressure formation.

Monitoring the quantity and quality of chest tube output is very important to help dictate ongoing chest tube management. The two primary indications for transfer to the operating room for thoracotomy and thoracic exploration include 1.5L of bloody output immediately following placement or >200cc per hour of bloody output during the first 4 hours following placement [12]. Both signify a likely ongoing hemorrhagic process that requires operative intervention.

There are no consensus guidelines for the management of suction and decisions for chest tube removal [3]. The surgeon must consider the indication for chest tube placement, ongoing physiology of the patient, positive pressure ventilation dependency, or if the patient has developed a bronchopleural fistula. The following are a few guiding principles to consider: chest tubes can be removed when pneumothorax and air leak have resolved or there is <200cc of liquid output on consecutive days, and removal of tubes should occur between end-inspiration and end-expiration with the wound covered by an occlusive dressing for a minimum of 48 hours [13]. Serial CXRs following suction changes and after removal are strongly recommended if able.

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