Tube Thoracostomy Management

Updated: Apr 26, 2018
  • Author: Pranit Chotai, MD; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
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Overview

Background

Tube thoracostomy is often used to treat pleural effusion, pneumothorax, hemothorax, hemopneumothorax, and empyema. [1] The use of chest tubes was described as long ago as the time of Hippocrates (c. 460 BCE), when metal tubes were placed to treat empyema. [2, 3] Playfair, treating a child with empyema thoracis in 1873, is credited with being the first physician to use a water-sealed chest drainage system. Chest tube placement techniques evolved and were perfected during the 1918 flu epidemic and subsequently in the management of combat injuries during World War II. [3]

Physiologically, a potential space exists between the parietal pleura (abutting chest wall) and the visceral pleura (abutting lung parenchyma), which normally contains less than 25 mL of pleural fluid. The presence of excess fluid, air, blood, chyle, or pus in this pleural space results in displacement of pulmonary volume, which disrupts gas exchange. Prompt drainage of this abnormal intrapleural collection is required to restore normal pulmonary mechanics.

In other scenarios, indwelling chest tubes may be placed for postoperative management of patients after lung resections in order to facilitate creation of space for lung reexpansion. Because chest tubes are used to treat patients with both medical and surgical diagnoses, physicians should be familiar with the appropriate management of patients with these drains.

Despite its wide spread use, high-quality, prospective data to guide postplacement management of chest tubes are lacking and current management of patients with chest tubes is driven mainly by anecdotal experience and institutional protocols. [4, 5]  Improper management of inserted chest tubes results in premature or delayed removal, both of which may be associated with increased morbidity, hospital stay, and costs.

This article discusses the essential and pragmatic concepts of postplacement management of patients with chest tubes. For details on the technique for chest tube placement, see Tube Thoracostomy. [6]

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Indications

Indications for chest drains include the following:

  • Pneumothorax (spontaneous, tension, iatrogenic, traumatic)
  • Pleural collection - Pus ( empyema), blood (hemothorax), chyle ( chylothorax)
  • Malignant effusions (pleurodesis)
  • Postoperative
  • Video-assisted thoracoscopic surgery (VATS)
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Contraindications

The need for emergency thoracotomy is an absolute contraindication for tube thoracostomy.

Relative contraindications include the following:

  • Coagulopathy
  • Pulmonary bullae
  • Pulmonary, pleural, or thoracic adhesions
  • Pulmonary abscess
  • Loculated pleural effusion or empyema
  • Skin infection at the chest tube insertion site
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