What are the guidelines for performing and managing a thoracostomy (chest tube insertion) procedure?

Guidelines for Performing and Managing Thoracostomy (Chest Tube Insertion)

Thoracostomy should be performed using small-bore catheters (10-14F) as the initial choice for most pleural effusions, with ultrasound guidance to mark the optimal insertion site, and following the Seldinger technique for safer insertion. 1

Indications for Thoracostomy

• Pleural Effusions

  • Frank pus (empyema)
  • Pleural fluid pH <7.2
  • Loculated pleural collections
  • Large symptomatic effusions causing respiratory compromise
  • Malignant effusions requiring drainage for symptom relief
  • Recurrent symptomatic effusions after failed therapeutic thoracentesis 1

• Pneumothorax

  • Tension pneumothorax
  • Traumatic pneumothorax
  • Hemothorax
  • Persistent air leak 2

Pre-Procedure Preparation

1. Equipment Selection

   • Small-bore catheters (10-14F) for most pleural effusions 1
   • Larger tubes may be considered for hemothorax or empyema if needed
   • Avoid trocars due to increased risk of organ injury 1

2. Imaging Guidance

   • Ultrasound guidance is strongly recommended to mark the optimal site 1
   • Confirm the presence and location of fluid/air before insertion

3. Patient Positioning

   • Position patient with arm raised above head on the affected side
   • Slight elevation of the torso (30-45 degrees) if tolerated

Insertion Technique

1. Site Selection

   • Use the 'safe triangle' bordered by:
     • Anteriorly: lateral edge of pectoralis major muscle
     • Posteriorly: anterior border of latissimus dorsi
     • Inferiorly: line superior to the horizontal level of the nipple
     • Apex: below the axilla 1
   • For pneumothorax: 2nd intercostal space, mid-clavicular line
   • For fluid: 4th-5th intercostal space, mid-axillary line 3

2. Procedure Steps

   • Perform aseptic technique with sterile field
   • Administer local anesthesia (lidocaine) to skin, subcutaneous tissue, periosteum, and pleura
   • Remember intercostal nerves run on the undersurface of the rib above 3
   • For small-bore catheters: Use Seldinger technique
   • For larger tubes: Use blunt dissection technique
   • Ensure tube is directed posteriorly for fluid or anteriorly for air 1, 4

3. Tube Fixation

   • Secure tube to chest wall with sutures
   • Apply occlusive dressing around insertion site
   • Connect to underwater seal drainage system 3

Post-Insertion Management

1. Drainage System

   • Connect to underwater seal drainage system
   • Keep drainage system below patient's chest level
   • For large effusions, limit initial drainage to 1-1.5L to prevent re-expansion pulmonary edema 1

2. Monitoring

   • Obtain post-insertion chest X-ray to confirm position
   • Monitor vital signs, respiratory status, and drainage output
   • Assess for complications (pain, bleeding, subcutaneous emphysema)

3. Ongoing Care

   • Daily assessment of tube function and drainage
   • Regular dressing changes using aseptic technique
   • Monitor for infection at insertion site

Removal Criteria

• Remove chest drain when:
  • Air leaks are no longer observed
  • Serous pleural drainage is <300 mL/day 2
  • Clinical improvement is achieved
  • Radiographic confirmation of lung re-expansion

Complications and Prevention

1. Insertion Complications

   • Organ injury (lung, liver, spleen, heart)
   • Intercostal vessel injury
   • Misplacement (subcutaneous, fissural, intraparenchymal)
   • Prevention: Use imaging guidance, follow anatomical landmarks, use blunt dissection 1, 5

2. Post-Insertion Complications

   • Re-expansion pulmonary edema
   • Empyema (1-2% of cases)
   • Retained hemothorax
   • Tube occlusion or dislodgement 4, 5
   • Prevention: Proper tube size selection, careful initial drainage, secure fixation

Special Considerations

1. Pediatric Patients

   • Use age-appropriate tube sizes
   • Consider sedation in addition to local anesthesia
   • More vigilant monitoring for respiratory compromise 2

2. Patients with Tracheostomy

   • Special attention to ventilation during procedure
   • Consider positioning to optimize both tracheostomy and chest tube function 2

3. Surgical Referral

   • Consider surgical referral if no improvement after 7 days of drainage and antibiotics
   • For recurrent pneumothorax, surgical options include pleurectomy or pleural abrasion 2, 1

The overall complication rate for thoracostomy procedures is approximately 14%, with 9% classified as major complications 5. Proper training, adherence to anatomical guidelines, and use of imaging significantly reduce these risks.