What is the difference between thoracostomy and chest tube (chest tube insertion) for drainage of the thoracic cavity?

Thoracostomy vs Chest Tube: Understanding the Difference

A thoracostomy is the surgical creation of an opening in the chest wall, while a chest tube (chest tube insertion) is the placement of a drainage tube through this opening into the pleural space to evacuate air or fluid. The distinction is important as thoracostomy refers to the procedure of creating the opening, while chest tube insertion involves both creating the opening and placing a drainage device.

Key Differences Between Thoracostomy and Chest Tube

Thoracostomy

• Refers specifically to the surgical creation of an opening in the chest wall
• May be performed without tube placement in emergency situations (needle thoracostomy)
• Serves as the first step in chest tube insertion
• Can be a standalone procedure in emergency settings for tension pneumothorax

Chest Tube Insertion

• Involves both creating the thoracostomy and placing a drainage tube
• Requires connection to a drainage system (underwater seal, Heimlich valve, etc.)
• Provides continuous drainage of the pleural space
• Requires ongoing management until removal

Insertion Techniques

Seldinger Technique (Preferred for Small-Bore Tubes)

• Recommended by the British Thoracic Society for small-bore drains 1, 2
• Involves:
  1. Initial needle insertion with guidewire placement
  2. Dilation of the tract
  3. Tube insertion over the guidewire
• Associated with less patient discomfort and fewer complications

Blunt Dissection Technique (For Larger Tubes)

• Used primarily for larger tubes (>24F) 3
• Involves surgical dissection through chest wall layers
• More invasive than Seldinger technique
• Higher risk of complications

Tube Size Selection

• Small-bore tubes (≤14F):

  • Recommended as first-line for spontaneous pneumothorax in non-ventilated patients 1, 3
  • Adequate for most pleural effusions
  • Associated with less pain and patient discomfort 1
  • Recommended by the British Thoracic Society for initial drainage of pleural infection 1

• Large-bore tubes (>14F):

  • May be needed for hemothorax or large air leaks 2
  • Considered when small-bore tubes fail to provide adequate drainage
  • Associated with increased post-treatment pain 1

Post-Insertion Management

1. Immediate post-insertion:

   • Chest radiograph to confirm position 1, 2
   • Connection to underwater seal or one-way valve system 1

2. Ongoing management:

   • Monitor for air leak, fluid drainage, and tube position
   • Never clamp a bubbling chest tube due to risk of tension pneumothorax 1, 2
   • Keep drainage system below chest level at all times 1

3. Removal criteria:

   • No air leak
   • Drainage <100-150 mL per 24 hours for fluid
   • Confirmed lung expansion on chest radiograph 2

Complications

Common Complications

• Pain at insertion site
• Tube blockage or displacement
• Subcutaneous emphysema
• Infection (1-6%) 2

Serious Complications

• Organ injury (lung, heart, major vessels, abdominal organs)
• Hemothorax (0.1-11%)
• Pneumothorax (1-4%)
• Air embolism (rare but potentially fatal) 2, 4

Clinical Pitfalls to Avoid

1. Never use substantial force or a trocar during insertion 1

   • Can cause sudden chest penetration and damage to intrathoracic structures
   • Associated with higher complication rates

2. Never clamp a bubbling chest tube 1

   • Risk of converting simple pneumothorax to tension pneumothorax

3. Maintain sterile technique 1

   • Essential to prevent wound site infection or secondary empyema
   • Use sterile gloves, gown, equipment, and sterile towels

4. Avoid contamination of pleural fluid samples 1

   • Local anesthetic or heparin can alter pH measurements
   • Delays in processing can affect results

Special Considerations

• Persistent air leaks: Consider applying suction (high volume, low pressure at -10 to -20 cm H₂O) if air leak persists beyond 48 hours 2

• Pleural infection: Small-bore tubes (14F or smaller) are recommended for initial drainage 1

• Post-procedure follow-up: Arrange follow-up within 7-10 days after discharge with chest radiograph to confirm resolution 2

In summary, while thoracostomy refers to the creation of an opening in the chest wall, chest tube insertion encompasses both creating this opening and placing a drainage tube. Understanding this distinction and following evidence-based guidelines for tube selection, insertion technique, and management is crucial for optimizing patient outcomes and minimizing complications.