What patient anatomical factors can make chest tube insertion difficult?

Anatomical Factors That Make Chest Tube Insertion Difficult

Obesity with BMI >30 kg/m² is the single most significant anatomical factor that increases chest tube complications and malpositioning, with thick chest walls creating added distance to the pleural cavity and making proper placement technically challenging. 1

Body Habitus Factors

Obesity

• Morbidly obese patients present substantial challenges due to thick chest walls that increase the distance to the mitral valve and pleural space 2
• BMI >30 kg/m² is an independent predictor of chest tube complications and malpositioning 1
• Thick subcutaneous tissue makes it difficult to palpate rib intercostal spaces, which is essential for proper tube placement 2
• Fat distribution affects the ability to compress soft tissues and achieve adequate exposure through the working port 2

Extreme Muscularity

• Extremely muscular patients with thick chest walls face similar challenges to obese patients 2
• Muscular soft tissues are difficult to compress, making exposure through the right-chest working port particularly challenging 2
• The added distance through muscle to reach the pleural cavity complicates accurate tube positioning 2

Skeletal Deformities

Kyphoscoliosis

• Kyphoscoliosis causes cardiac migration into the left chest, limiting working angles between the sternum and spine 2
• This deformity creates additional distance between the incision site and the heart 2
• The altered anatomy compromises exposure and makes it difficult to achieve proper tube trajectory 2
• Kyphoscoliosis is listed as a relative contraindication for minimally invasive approaches due to these technical challenges 2

Pectus Excavatum

• Pectus excavatum similarly compromises exposure by altering normal thoracic anatomy 2
• Cardiac migration into the left chest occurs, reducing the working space available for tube insertion 2
• The deformity limits the ability to achieve proper angles for tube placement 2

Previous Thoracic Interventions

Prior Chest Procedures

• History of chest trauma, previous chest tubes, pneumothorax, or right chest surgery typically results in adhesions that add time and morbidity 2
• Dense adhesions increase the risk of pulmonary injury during tube insertion 2
• Prior pleurodesis creates particularly challenging adhesions that may necessitate alternative approaches 2
• Previous chest procedures may require thoracoscopy through a 5-mm camera port to assess safety before proceeding with tube placement 2

Breast Anatomy (Female Patients)

Breast Tissue Considerations

• Large breasts require retraction medially to enhance exposure of the lateral chest wall 2
• The location and extent of incisions must be planned relative to breast position to avoid subsequent bra irritation 2
• Breast implants require preoperative assessment to ensure appropriate intercostal space access 2
• Compromised implant integrity must be identified preoperatively, and in certain cases, implants may need temporary removal 2

Diaphragmatic Position

Elevated Hemidiaphragm

• An elevated hemidiaphragm obstructs visualization and makes passage of instruments more difficult 2
• This anatomical variant increases the risk of diaphragmatic injury during tube insertion 2
• Solutions include reverse-Trendelenburg positioning and diaphragmatic retention sutures 2

Groin Anatomy (For Femoral Cannulation)

Femoral Access Considerations

• Inguinal or femoral hernias (or history of repaired hernia) complicate femoral access 2
• Large pannus obscures anatomical landmarks and increases infection risk 2
• Fungal infiltration of the groin creates additional barriers to safe access 2
• Absent or diminished femoral arterial pulses indicate vascular disease that precludes safe femoral cannulation 2

Clinical Implications

Emergency department placement and placement by less experienced operators compound the difficulties created by challenging anatomy, with malpositioning rates increasing from 6.5% to 53.5% when tubes are initially malpositioned. 1 Early complications from malpositioning increase the likelihood of late complications from 4.3% to 13.6%, and patients with late complications have hospital stays averaging 7.56 days longer than those without complications 1.