9: Techniques for Pleural Drainage and Chest Tube Management

Introduction

The concept of chest tube drainage was first advocated by Hippocrates when he described the treatment of empyema by means of incision, cautery, and insertion of metal tubes.¹ The technique was not widely used until the influenza epidemic of 1917 which saw an increased use of intercostal drainage for postpneumonic empyema.² The use of chest tubes was imperative in the management of World War II causalities requiring thoracotomy and was reported in 1922 for postoperative care.³ The concept of emergency thoracostomy for acute trauma gained wider popularity following the Korean War in 1945.⁴ Today the use of chest tubes is part of the day-to-day management of acute trauma and care of thoracic surgery patients.

Chest tubes are indicated for both emergent and elective situations.^4-6 The most common indication for tube thoracostomy is pneumothorax and/or hemothorax. Other indications are summarized in Table 9-1. There are no absolute contraindications to drainage by means of chest tube, especially in the case of life-threatening emergency.⁴ Relative contraindications to chest tube insertion include postoperative inflammatory and infective pleural space adhesions, presence of a diaphragmatic hernia, or hepatic hydrothorax with documented coagulopathy.⁷

Technique

The essential steps to inserting a pleural drainage tube are summarized in Table 9-2. The technique can also be viewed online.⁸ Good insertion technique and appropriate post-insertion care are associated with less morbidity and shorter hospital stays.⁹ The most common site of insertion is the “safe triangle,” which as the name implies, is the safest entry into the chest.^10,11 The boundaries of this triangle are identified by the anterior border of the latissimus dorsi, the lateral border of the pectoralis major muscle, and a line superior to the horizontal level of the nipple and an apex below the axilla (Fig. 9-1). In this space, the likelihood of damaging vital structures during insertion is considerably low.¹² As the diaphragm can rise to the fifth rib at nipple level during expiration, chest tubes should be placed above this level to avoid inadvertent damage to abdominal structures.