Thoracostomy Guidelines: Procedure and Management
Thoracostomy should be performed using ultrasound guidance with small-bore catheters (10-14F) via the Seldinger technique for most pleural effusions, while following the anatomical 'safe triangle' for insertion to minimize complications. 1
Indications for Thoracostomy
Thoracostomy is indicated for:
- Pneumothorax (especially large or symptomatic)
- Hemothorax
- Persistent air leak
- Frank pus (empyema)
- Pleural fluid with 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
Procedure Technique
Pre-procedure Preparation
- Obtain informed consent
- Review imaging to confirm indication and location
- Prepare sterile field and equipment
- Position patient appropriately (typically semi-recumbent or lateral decubitus)
Insertion Site Selection
- Use the 'safe triangle' bordered by:
- Lateral edge of pectoralis major muscle
- Anterior border of latissimus dorsi
- Line superior to the horizontal level of the nipple 1
Recommended Technique
- Ultrasound guidance is strongly recommended to mark the optimal insertion site
- Small-bore catheters (10-14F) are recommended for most pleural effusions
- Seldinger technique is preferred for small-bore drains
- Blunt dissection for larger tubes
- Never use trocars due to increased risk of organ injury 1
Tube Size Selection by Indication
| Indication | Recommended Drain Size | Technique | Imaging Guidance |
|---|---|---|---|
| Pleural effusion | 10-14F | Seldinger | Ultrasound |
| Malignant effusion | 10-14F | Seldinger | Ultrasound |
| Loculated collection | 10-14F | Seldinger | Ultrasound |
| Large effusion | 10-14F | Seldinger | Ultrasound |
| Pneumothorax | 10-14F | Seldinger | Ultrasound |
Post-Procedure Management
- Connect chest drain to underwater seal drainage system
- Keep drainage system below patient's chest level
- Consider clamping the drain for 1 hour after initial 1-1.5L drainage to prevent re-expansion pulmonary edema
- Perform daily assessment of tube function and drainage
- Monitor for complications 1
Criteria for Chest Tube Removal
- No air leaks observed
- Serous pleural drainage <300 mL/day
- Clinical improvement achieved
- Radiographic confirmation of lung re-expansion 1
Complication Prevention
- Do not routinely insert chest drains for all pleural effusions
- Do not use substantial force during insertion
- Never clamp a bubbling chest drain
- Avoid rapid drainage of large effusions
- Never place drains without imaging guidance 1
Common Complications to Monitor
- Re-expansion pulmonary edema
- Infection/empyema
- Organ injury
- Tube malposition (occurs in up to 31% of cases) 2
- Retained hemothorax
Special Considerations
Pediatric Patients
- Use age-appropriate tube sizes
- Consider sedation in addition to local anesthesia
- More vigilant monitoring for respiratory compromise 1
COVID-19 Precautions
- Consider chest tube insertion as an aerosol-generating procedure
- Use appropriate PPE (Level 2)
- Take extra precautions to avoid open communication with pleural space 1
Surgical Referral Criteria
Consult thoracic surgery if:
- No improvement after 7 days of drainage and antibiotics
- Recurrent pneumothorax
- Persistent sepsis despite appropriate antibiotic therapy
- Trapped lung requiring definitive management 1
Evidence Insights
Recent research has shown that small-bore chest tubes (20-22 Fr) are as effective as larger tubes (28 Fr) for emergent management of traumatic pneumothorax or hemothorax, with no significant differences in complications, need for additional tube placement, or thoracotomy 3. This supports the guideline recommendation for using smaller tubes when appropriate.
However, complication rates for thoracostomy remain significant (reported as 14% in one study, with 9% classified as major) 2, emphasizing the importance of proper technique, training, and ultrasound guidance as recommended in the guidelines.