Chapter 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 In 1922, Lilienthal described the largest operative experience with use of postoperative chest tubes after 31 lobectomies for suppurative bronchiectasis and use of a chest tube with its end under antiseptic fluid, known as Kenyon’s drain.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 may be used for either emergent or elective drainage.^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 or other pleural space adhesions or pleural symphysis, presence of a diaphragmatic hernia, or hepatic hydrothorax with documented coagulopathy.⁷

TECHNIQUE

Increasingly, small-bore (<20F) chest tubes, or even percutaneously placed pigtail catheters measuring 8F to 14F, are being used in the treatment of pneumothoraces not related to recent thoracic surgery or trauma. In addition, small-bore tubes are being used to treat malignant pleural effusion and pleural infections.⁸ Whether a pigtail catheter or chest tube is placed depends largely on the operator’s skill set and the patient’s habitus. One cannot control the direction (or ultimate position) of the pigtail on insertion, and therefore extra caution should be used in deciding to use and implementing this method. In a thin, stable patient, a percutaneous pigtail is a reasonable option, but in an obese patient or in one in whom a pocket of air or fluid is more challenging to locate, a traditional chest tube should be used. Pigtails have been “placed” into the extrathoracic space in patients with a large chest wall.

The essential steps to inserting a pleural drainage tube are summarized in Table 9-2. The technique can also be viewed online.⁹ Good insertion technique and appropriate postinsertion care are associated with less ...