Chapter 44. Tube Thoracostomy

• Pneumothorax.
• Hemothorax.
• Chylothorax.
• Empyema.
• Pleural effusion (persistent).
• Thoracic trauma or surgery.

Absolute

• None.

Relative

• Coagulopathy.
• Overlying skin infection.
• Overlying chest wall malignancy.
• Intrapleural adhesions.
• Loculated pleural collection.

• The patient should be supine with the ipsilateral arm positioned over the head to facilitate adequate exposure of the anterolateral thoracic wall.

• A chest radiograph should be obtained at the conclusion of the procedure to assess placement.
• The patient's hemodynamic status should be monitored for signs of cardiopulmonary distress.
• The chest tube output should be recorded; if there is considerable blood loss a thoracotomy should be considered.
• Each time the patient is evaluated, assessment of the nature of the output and presence of an air leak should be noted.
• Typically, when the patient has clinically improved, the output is decreased (values vary based on surgeon preference), and an air leak has resolved the chest tube is transitioned from suction to water seal in anticipation of removal.
• To remove a chest tube, great care must be taken to prevent introduction of air into the pleural space.
  • An assistant should hold pressure with petroleum gauze and dry gauze over the tract as the tube is rapidly removed at the end of an inspiration.
  • The previously placed U-stitch may be tied to close the skin opening; however, this is optional.
• A chest radiograph should be obtained to assess for interval development of a pneumothorax.

• Bleeding: intercostal neurovascular or great vessel injury.
  • May present with hemorrhage.
  • Treatment includes resuscitation, hemostatic control through possible thoracotomy, and consultation with a cardiovascular surgeon.
• Solid organ injury: pulmonary parenchymal injury, diaphragmatic injury, cardiac injury, splenic injury on the left side, or hepatic injury on the right side.
  • May present with bleeding or dysfunction of the involved organ.
  • Treatment is directed at the affected organ system.
• Persistent air leak.
  • May manifest if a bronchopleural fistula is present or pulmonary parenchymal injury has occurred.
  • Treatment would require surgical management by a thoracic surgeon.