Chapter 32

### Introduction

Tube thoracostomy, commonly known as chest tube placement, is the insertion of a tube into the pleural space typically to drain air or fluid, although the procedure may be performed for pleurodesis or lysis of adhesions in the pleural space.

### Definitions and Terms

• ▪  Pneumothorax: Accumulation of air in the pleural space
• ▪  Pleural effusion: Accumulation of fluid in the pleural space
• ▪  Pleurodesis: Medical treatment for refractory pleural effusion (often malignant) or pneumothorax in which a chemical is instilled into the pleural space to adhere the pleural and pulmonary surfaces to one another

### Techniques

• ▪  There are a variety of indications for tube thoracostomy.
• —Aspiration of air from a pneumothorax or with bronchopleural fistula
• —Therapeutic drainage of serous, infected, or malignant fluid from the chest
• —Postoperative drainage of the chest following thoracic or cardiac surgery
• —Trauma
• ▪  Contraindications.
• —Coagulopathy
• ▪  The patient should be consented, prepped, and the universal protocol performed as in Section I.
• ▪  The patient is typically positioned on supine with the arm abducted over the head (Figure 32-1) for tube insertion in the mid-axillary line, although alternative positions may be appropriate.
• ▪  Local anesthesia is instilled into the area of insertion (Figure 32-2).
• ▪  A small 2-cm incision is made.
• ▪  The appropriate tube is inserted depending on the pathology.
• —Pneumothorax—small bore tube (ie, 8-18 French)
• —Fluid drainage—large bore tube (ie, 18 and above French)
• ▪  Small tubes can be inserted using Seldinger technique.
• ▪  Larger tubes are inserted using blunt dissection (Figures 32-3, 32-4, and 32-5).
• ▪  If blunt dissection is used, a hemostat is used to guide the tube into the thoracic cavity (Figure 32-6).
• ▪  The tube should be directed appropriately depending on the nature of the pathology, that is, cephalad for a pneumothorax (Figure 32-7) or posteriorly and inferiorly for an effusion.
• ▪  The chest tube should be attached to a drainage system and monitored for ongoing fluid drainage and air leak.
• ▪  A chest x-ray should be performed following the procedure to ascertain tube position (Figure 32-8).

###### Figure 32-1.

Draped and prepped incision site in med-axillary line.

###### Figure 32-2.

Skin infiltration with local anesthetic.

###### Figure 32-3.

Blunt finger dissection.

###### Figure 32-4.

Hemostat dissection.

###### Figure 32-5.

Widening of pleural opening with hemostat.

###### Figure 32-6.

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