What are the potential complications of chest tube insertion?

Major Complications of Chest Tube Insertion

The most critical complications you need to worry about are organ penetration (lung, liver, spleen, stomach, heart, great vessels) which can be fatal, and these occur most commonly when sharp metal trocars are used during insertion. 1

Life-Threatening Complications During Insertion

Organ Injury (Most Serious)

• Penetration of major organs including lung, stomach, spleen, liver, heart, and great vessels are potentially fatal complications 1
• These catastrophic injuries occur significantly more often when sharp metal trocars are inappropriately used during the procedure 1, 2
• Hemothorax from vascular injury is a recognized serious complication 2, 3
• Lung lacerations can occur with improper technique 2

Critical Pitfall to Avoid

• Never use a trocar or substantial force during insertion - this is the primary cause of organ injury 1, 2
• Use blunt dissection for large tubes (>24F) or Seldinger technique for smaller tubes instead 1, 4

Post-Insertion Complications

Tension Pneumothorax from Tube Clamping

• Never clamp a bubbling chest tube - this can convert a simple pneumothorax into a life-threatening tension pneumothorax 1
• Even non-bubbling tubes should not usually be clamped 1
• If a clamped drain patient becomes breathless or develops subcutaneous emphysema, immediately unclamp and seek help 1

Pleural Infection/Empyema

• Empyema occurs in approximately 1% of chest tube insertions overall 1
• In trauma cases, rates can reach 6% 1
• Use strict aseptic technique during insertion and any manipulation of the drainage system 1
• Residual hemothorax significantly increases empyema risk (2-25% in trauma) 5

Subcutaneous Emphysema

• Develops when air communicates with subcutaneous tissues through a malpositioned, kinked, blocked, or clamped tube 1
• Usually cosmetically important only and subsides in days 1
• Rarely causes acute airway obstruction or thoracic compression requiring emergency intervention (tracheostomy, skin decompression, or large bore subcutaneous drains) 1

Tube Malposition and Dysfunction

• Malpositioned tubes have a 7.2-fold increased likelihood when placed outside trauma centers 6
• Results in residual hemothorax (6.3-fold increased risk) or residual pneumothorax (6.7-fold increased risk) 6
• Always obtain a chest radiograph after insertion to verify position and rule out iatrogenic pneumothorax 1

Common but Less Severe Complications

Tube-Related Issues

• Pain at insertion site 4
• Drain blockage 4
• Accidental dislodgment 4
• Need for second chest tube placement (3.77-fold increased risk with outside placement) 6

Re-expansion Pulmonary Edema

• A dreaded complication that can occur after rapid lung re-expansion 4

Key Management Principles

Ensure proper tube function by:

• Checking patency by flushing with 20-50ml normal saline 5
• Keeping underwater seal drainage system below patient's chest level at all times 1
• Performing imaging (chest X-ray or contrast-enhanced CT) if drainage is poor despite patent tube 5

For residual collections:

• Place a second chest tube rather than relying solely on antibiotics 5
• Consider intrapleural fibrinolytics (streptokinase 250,000 IU twice daily for 3 days or urokinase 100,000 IU once daily for 3 days) 5