What are the indications for chest tube thoracostomy in adults and children with a history of trauma, pulmonary disease, or post-surgical complications?

Indications for Chest Tube Thoracostomy

Chest tube thoracostomy is indicated for pneumothorax (especially tension pneumothorax), hemothorax requiring drainage, and pleural effusions causing respiratory compromise, with specific thresholds guiding the decision for traumatic hemothorax and post-surgical effusions.

Trauma-Related Indications

Hemothorax

• Insert a chest tube immediately when initial drainage yields >1,500 mL of blood or when ongoing blood loss exceeds 200 mL per hour 1
• Progressive massive hemorrhage despite closed thoracic drainage mandates chest tube placement as a bridge to potential thoracotomy 1
• Establish large-bore IV access and initiate massive transfusion protocol simultaneously with tube placement to prevent coagulopathy 1

Pneumothorax

• Suspected tension pneumothorax or low output state in the pre-hospital setting warrants immediate thoracostomy, with 61% of field thoracostomies performed for these appropriate indications 2
• Simple pneumothorax in trauma patients typically requires chest tube placement to prevent progression, particularly in mechanically ventilated patients 2

Post-Surgical Indications

Post-Thoracic Surgery

• Most postoperative pleural effusions do not require intervention, and radiological features alone should not dictate the need for chest tube placement 3
• Ultrasound-guided thoracocentesis has largely replaced surgical tube thoracostomy for post-surgical effusions and is both effective and well tolerated 3
• Use a single chest drain for management of postoperative pleural effusion when drainage is necessary 3
• Remove the chest drain as soon as air leaks are no longer observed and when serous pleural drainage is <300 mL/day 3

Post-Cardiac Surgery

• Postoperative pleural effusions are common after cardiothoracic surgery but have no demonstrated impact on mortality when managed conservatively 3
• Earlier drain removal following thoracic surgery, at higher than traditionally accepted drain outputs (450 mL/day), is safe and efficacious 3

Pulmonary Disease Indications

Pleural Effusions

• Symptomatic pleural effusions causing dyspnea or respiratory compromise require drainage, though thoracocentesis is often preferred over tube thoracostomy initially 3
• Complicated parapneumonic effusions or empyema require chest tube drainage with appropriate sizing 4

Pneumothorax in Non-Trauma Settings

• Large or symptomatic spontaneous pneumothorax warrants chest tube placement 4
• Small-bore chest tubes (≤14 French) are increasingly preferred for most non-traumatic pneumothoraces given their relative ease and patient comfort 4

Pediatric Considerations

Age-Appropriate Sizing

• Infant chest tubes should be 10F-12F 5
• Child chest tubes should be 16F-24F 5
• Pediatric patients with tracheostomies have higher complication rates, particularly those under 1-3 years of age, premature infants, and those weighing <2,000-3,000 g 3

Emergency Procedures

• Emergency thoracostomies in children are accompanied by more complications than elective procedures (75% versus 35%) 3
• Children without an artificial airway preoperatively have higher complication rates (55% versus 35%) 3

Critical Technical Considerations

Equipment Selection

• Adult chest tubes should be 28F-40F for traumatic hemothorax or hemopneumothorax 5
• Small-bore tubes (≤14F) are appropriate for simple pneumothorax or serous effusions 4
• Digital chest drainage systems should be used for suction drainage to optimize management 3

Procedural Safeguards

• Use ultrasound to assess anatomy and point of entry when available 5
• Perform universal protocol and time-out before starting 5
• Administer adequate local anesthesia and consider sedation for patient comfort 5
• Make the incision in the 4th or 5th intercostal space, dividing intercostal muscles along the superior border of the lower rib to avoid neurovascular bundle injury 1

Common Pitfalls to Avoid

• Never delay thoracostomy in unstable trauma patients for additional imaging—immediate surgical control is required 1
• Recognize that 28-31% of tubes are poorly positioned initially, with 17% requiring repositioning 5, 2
• Tube blockage is the most common cause of respiratory distress in patients with chest tubes 5
• Overall complication rates for chest tube thoracostomy range from 2-25%, with 9% classified as major complications requiring surgical intervention 6, 2
• Pre-hospital thoracostomies have the same potential risks as in-hospital procedures, requiring attention to insertion techniques under difficult conditions 2
• Do not use chest tubes routinely for postoperative effusions when thoracocentesis is adequate 3