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.

Potential Risks

• Bleeding.
• Infection.
  • Skin and subcutaneous infection.
  • Empyema.
• Risk of anesthetic if used.
• Death.
• Possible injury and need for repair of surrounding structures.
  • Intercostal neurovascular injury.
  • Great vessel injury.
  • Pulmonary parenchymal injury.
  • Diaphragmatic injury.
  • Cardiac injury.
  • Splenic injury on left side.
  • Hepatic injury on right side.
• Persistent air leak.
• Need for emergent thoracotomy or future additional procedures.

• Sterile gown and gloves, cap, mask, eye protection.
• Povidone-iodine or chlorhexidine preparation, sterile towels.
• Local anesthesia.
• Chest tube (varied sizes, depending on indication and size of patient).
• Chest tube management system.
• Scalpel, Kelly clamp, needle driver, scissors, nonabsorbable suture, Xeroform or petroleum gauze, sterile gauze, foam tape.

• The patient does not need to have an empty stomach although this is preferable if conscious sedation is used in the nonemergent setting.
• Preoperative antibiotics are not required.

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

• Local anesthesia with or without conscious sedation may be used.
  • When local anesthesia is used, infiltration of the skin, subcutaneous tissue, muscle, and parietal pleura provides the best anesthesia.
• Figure 44–1: A transverse skin incision parallel to the intercostal space is planned, usually at approximately the fourth or fifth intercostal space at the midaxillary or anterior axillary line.
  • The goal of this placement is to avoid the diaphragm, intra-abdominal organs, and breast tissue (in women), and to allow for placement anterior enough that the patient does not lie on the tube after placement.
• Figure 44–2A—C: The skin incision is made using a scalpel at one intercostal level below the planned entry site of the chest tube into the pleural space.
  • The subcutaneous tissue and intercostal muscles are dissected bluntly in a transverse direction using a hemostat or Kelly clamp until the parietal pleura is reached.
• Figure 44–3: During dissection of the subcutaneous tissue and muscles, the Kelly clamp should be directed cranially toward the rib above and the tips should be pointed toward the superior aspect of this rib to avoid the course of the intercostal neurovascular bundle inferior to each rib.
• Figure 44–4: Using a Kelly clamp, the pleural space is entered parallel to the ribs in a controlled fashion with the tips of the instrument closed.
  • Once the pleural space is penetrated, the clamp should be opened to allow egress of air or fluid.
  • A finger should be placed in the pleural space and swept to check for adhesions prior to tube placement.
• Figure 44–5: Once the pleural space is entered and freed of any adhesions, the chest tube is clamped at ...