Need le and Tu be

Thoracostomy

Ann Buchanan, MD

Key Points

• Do not confuse a pulmonary bleb or bul lae for a

pneumothorax.

• The neurovascular bundle runs inferior to each rib. Always

enter the thoracic cavity over the rib, never under.

INDICATIONS

Needle thoracostomy is indicated for emergent decompression of suspected tension pneumothorax. Tube thoracotomy is indicated after needle thoracostomy, for simple

pneumothorax, traumatic hemothorax, or large pleural

effusions with evidence of respiratory compromise.

CONTRAINDICATIONS

A pneumothorax on chest x-ray may be confused with a pulmonary bleb or bullae. Bullae and blebs are large gas-filled

spaces with thin walls where pulmonary parenchyma has

been destroyed, therefore greatly increasing alveolar size and

mimicking pneumothorax. These are frequently located in

the lung apices and are often seen in patients with severe

chronic obstructive pulmonary disease. It is essential to confirm the presence of a pneumothorax before placement of a

thoracostomy tube. See Chapter 24 for further clinical scenarios in which tube thoracostomy can be substituted for less

invasive or conservative management of pneumothoraces.

EQUIPMENT

Needle thoracostomy requires a 12- to 16-gauge angiocatheter, 3 to 4.5 inches in length, and a 5-10 mL syringe. Tube

thoracostomy requires a 36- to 40-F tube for hemothorax in

adults or 20- to 24-F tube in children. For a simple pneumothorax, an 18- to 28-F tube in adults or 14- to 16-F tube in

children is sufficient Additional supplies required for tube

thoracostomy placement include povidone-iodine (Betadine)

24

• Never advance or replace a tube that has migrated out

of the chest. Always place a new one.

A

Figure 7-1. A-0. Steps in tube thoracostomy

placement. (Repri nted with permission from Cothren C,

Biffl WL, Moore EE. Chapter 7. Trauma. In: Brunicardi FC,

Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB,

Pollock RE, eds. Schwartz's Principles of Surgery. 9th ed.

New York: McGraw-Hill, 201 0.)

NEEDlE AND TUBE THORACOSTOMY

A B

Col lection bottle Water seal

(

Water column

_.To wal l

SUCtiOn

Commercial thoracostomy tube drainage system

Figure 7-2. Diagram of tube thoracostomy and 3-bottle suction apparatus. Bottle A is connected to the

thoracostomy tube and collects pleural drainage for inspection and volume measurement. Bottle B acts as a simple

valve to prevent collapse of the lung if tubing dista l to this point is open to atmospheric pressure. Pulmonary air

leak can be detected by esca pe of bubbles from the submerged tube. Bottle C is a system to reg ulate the negative

pressure del ivered to the pleural space. Wall suction should be regulated to maintain continuous vigorous bubbling

from the middle open tube in bottle C. The resulting negative pressure in em H20 is equal to the difference in the

height of the fluid levels in bottles B and C. The com mercial Pleur-Evac system works in a similar manner. One end

is attached to the chest tube and the other to wall suction. Each chamber of the Pleur-Evac is filled with sterile

water to the level noted in the manufacturer's instructions. (Stone CK and Humphries RL: Longe: Current Diagnosis

and Treatment Emergency Medicine, 7th edition . McGraw-Hill, New York, 201 1 .)

CHAPTER 7

solution, sterile drapes, sterile gloves, 20 mL of 1 o/o lidocaine

with epinephrine, scalpel with #10 blade, large curved and

straight clamps, a needle driver, 2-0 silk suture, and a commercial or 3-bottle suction apparatus.

PROCEDURE

Needle thoracostomy is accomplished by cleansing the skin

in the upper chest and inserting the catheter over needle

into the second intercostal space (just over the third rib) at

the midclavicular line. Tension pneumothorax is confirmed with a sudden rush of air followed by improvement

in the patient's vital signs. Tube thoracostomy placement

should follow this procedure.

Tube thoracostomy is performed by first positioning

the patient with the arm of the affected side above the

patient's head and securing it with a soft restraint. The

chest wall is prepared with povidone-iodine solution and a

sterile field in the area of the fourth intercostal space

(below the fourth rib) at the mid to anterior axillary line.

The skin is then anesthetized with lidocaine, followed by

anesthesia of the deeper structures tunneling above the

fifth rib. Next, inject the intercostal muscles of the fourth

to fifth intercostal space, extending into the parietal pleura.

Additionally, procedural sedation or intercostal nerve

blocks may be used. After adequate anesthesia, a 2- to 3-cm

incision is made at the fifth rib between the mid and anterior axillary lines (Figure 7-1A). Using a large curved

clamp, tunnel up through the soft tissues over the fifth rib

to the fourth to fifth intercostal space. Then, using the

same clamp, puncture through the intercostal muscles,

using care not to enter the pleural space too deeply (Figure

7-1B). Open the jaws of the clamp to widen the hole in the

intercostal muscles. Insert a gloved finger through the tract

into the pleural cavity, using the curved clamp as a guide,

and then remove the clamp. Using your finger, ensure there

are no lung adhesions (Figure 7- 1 C). Using your finger or

the curved clamp, insert the chest tube into the thorax,

directing the tube posterior and superior, ensuring that all

the evacuation holes of the tube are within the thorax

(Figure 7- lD). The tube is then attached to a suction

device (Figure 7-2). Secure the tube by placing a simple

interrupted suture inferior to the tube. After tying a knot,

the remaining suture should be wrapped around the t ube

several times and a second knot tied. The skin above the

tube should then be closed with simple interrupted sutures.

Cover the wound with Vaseline gauze and a bandage. A

postprocedure chest x-ray should be ordered to check tube

position and confirm lung reexpansion (Figure 7-3).

COMPLICATIONS

The most common complication of needle thoracostomy

is failure to decompress. The patient's body habitus should

dictate the size of the catheter over needle being used. If a

.A. Figure 7-3. Chest x-ray showing the proper position

of a chest tube in the right lung.

3-cm catheter over needle fails to reach the pleural space,

the procedure should be immediately repeated with a

4.5-cm catheter over needle.

Infection remains a serious complication of tube thoracostomy for patients with chest trauma, with incidences

ranging from 2o/o to 25%. Thus strict sterile technique

should always be followed. Tubes should never be

advanced back into the thoracic cavity if they have

migrated out. A new tube should be placed. Bleeding can

also complicate tube thoracostomy. It may occur from

superficial venules or arterioles at the incision site or

from iatrogenic injury to the lung or abdominal organs.

Incorrect tube placement may cause kinking, subcutaneous placement, or evacuation holes remaining outside the

thoracic cavity, which results in either a nondraining tube

or one with a persistent air leak. Reexpansion pulmonary

edema, a rare but life-threatening complication, is more

common when the lung has been completely collapsed

for several days. Avoid this complication by placing the

tube to water seal after insertion if the lung has been collapsed for a prolonged period. This allows for a more

gradual reexpansion.

SUGGESTED READING

Brunett PH, et al. Pulmonary trauma. In: Tintinalli JE,

Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD.

Tintinalli's Emergency Medicine: A Comprehensive Study

Guide. 7th ed. New York, NY: McGraw-Hill, 20 1 1, pp.

1 744-1 758.

Joseph KT. Tube thoracostomy. In: Reichman EF, Simon RR.

Emergency Medicine Procedures. 1st ed. New York, NY:

McGraw-Hill, 2004, pp. 226-236.