What is the management for suspected chest tube malpositioning?

Management of Suspected Chest Tube Malpositioning

When chest tube malpositioning is suspected, obtain a portable chest radiograph immediately to confirm position, and if malfunction persists despite an apparently normal anteroposterior view, proceed directly to chest CT scan for definitive assessment, as CT is superior for detecting intrafissural and intraparenchymal malpositions that are frequently missed on plain films. 1

Initial Diagnostic Approach

Chest Radiography

• Obtain a portable chest radiograph as the first-line imaging modality to assess chest tube position after insertion 1
• Approximately 10% of chest tubes are malpositioned on initial post-insertion radiographs 1
• The anteroposterior portable view alone is insufficient for detecting many malpositions, particularly intrafissural placement 2
• A lateral radiograph should be obtained when tube malfunction is suspected, as it can confirm intrafissural positioning that may appear normal on AP views 2

Advanced Imaging with CT

• Proceed to chest CT scan when clinical evidence of tube malfunction exists despite apparently normal plain radiographs 3, 4
• CT scanning reveals a true malposition rate of 30% in critically ill patients—significantly higher than the 10% detected by radiography alone 4
• CT is essential for identifying intrafissural (21% of tubes) and intraparenchymal (9% of tubes) malpositions 4
• CT can detect unusual malpositions such as intrathoracic but extrapleural placement that explain persistent pneumothorax despite apparent radiographic improvement 5

Clinical Assessment of Tube Function

Signs of Malposition

• Persistent pneumothorax despite chest tube placement indicates possible malposition 5
• Poor drainage of pleural air or fluid collections suggests tube malfunction, occurring in 67% of intrafissural malpositions 2
• Sudden cessation of drainage should prompt evaluation for tube obstruction or malposition 6
• Check for tube kinking, especially with small soft drains in mobile patients 6

Respiratory Swing Assessment

• Assess the respiratory swing of fluid in the chest tube to confirm proper positioning in the pleural cavity 6
• Absence of respiratory swing may indicate extrapleural positioning or complete lung re-expansion 6

Management Based on Position

Confirmed Malposition with Clinical Dysfunction

• Replace the chest tube when malposition causes clinically relevant malfunction (occurs in approximately 6% of all inserted tubes) 7
• Intrafissural tubes causing poor drainage require repositioning or placement of additional tubes in 75% of cases 2
• Intraparenchymal or extrapleural tubes should be removed and replaced with proper intrapleural positioning 5, 4

Malposition Without Clinical Dysfunction

• Intrafissural or minor malpositions without evidence of clinical malfunction may be observed if drainage is adequate 7
• Continue monitoring with serial chest radiographs to ensure ongoing effectiveness 1

Prevention Strategies

Insertion Technique

• Avoid using a trocar for percutaneous chest tube insertion, as trocar use is the only significant predicting factor for malposition (p=0.032) 4
• Use blunt dissection technique without trocar to reduce malposition risk from 30% to significantly lower rates 4
• Be particularly cautious in COPD patients with wide retrosternal airspace, as they are at higher risk for mediastinal penetration 3

Approach Selection

• Both ventral (2nd-3rd intercostal space) and lateral (4th-6th intercostal space) approaches are acceptable 7
• Lateral approach has significantly higher risk of intrafissural malposition (21% vs 0%, p=0.013) compared to ventral approach 7
• Consider ventral approach when precise pleural cavity access is critical 7

Critical Safety Considerations

• Never clamp a bubbling chest tube, as this can cause fatal tension pneumothorax 6
• Keep the drainage system below the patient's chest level at all times 6
• Manage patients with chest tubes on specialized wards with trained staff 6
• If air leak persists beyond 4 days, consider surgical evaluation 6

Common Pitfalls

• Relying solely on anteroposterior portable radiographs misses 20% of malpositions that are visible only on CT 4
• Assuming adequate position based on partial clinical improvement when the tube may be extrapleural 5
• Using trocar insertion technique, which triples the risk of malposition 4
• Failing to obtain lateral radiographs when intrafissural placement is suspected on AP view 2