Introduction:
Thoracostomy is a technique that uses a thin plastic tube placed into the pleural space (the area present between the chest wall and lungs). It is placed by a medical expert person. The chest tube helps in the drainage of fluid or air out of the area between the lungs and the chest wall. It assists in managing pleural effusions, pneumothorax, lung infections, and some other conditions. It is incorporated by doctors in both emergencies and treating chronic conditions. This tube might be attached to a suction device to remove excess fluid or air or just to deliver medications into the pleural space.
What Is Tube Thoracostomy?
Tube thoracostomy is a technique that places a thin and hollow plastic tube amidst the ribs and into the chest to eliminate fluid or air from around the lungs, present in too many amounts. The tube gets frequently hooked up to a suction machine to assist in proper drainage. The tube remains in the chest until all or most of the air or fluid has drained out, frequently within a few days. Special medicines are sometimes given via a chest tube when the fluid or air does not resolve within a few days.
Despite the numerous benefits of TT drainage, the potential for morbidity and mortality still persists significantly. Some of the frequently occurring but serious complications are abdominal or thoracic injury, fistula formation, and vascular trauma. However, more commonly occurring complications are recurrent pneumothorax, insertion site infection, and nonfunctioning or malpositioned TT. These also signify a source of morbidity and cost of treatment, which is quite significant.
What Conditions Can a Tube Thoracostomy Treat?
A tube is inserted to drain air or fluid present in the chest. Conditions that are treated with a thoracostomy mostly are:
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Pneumothorax - a condition in which the lungs collapse.
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Pleural Effusion - A condition in which fluid accumulates around the lungs.
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Empyema - A condition in which pus is present in the pleural space.
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Hemothorax - Hemothorax is a condition in which blood is present in the chest cavity.
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Chylothorax - Presence of lymph in the chest cavity is chylothorax.
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Certain lung infections.
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Post-surgical use in thoracic or cardiac surgery.
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Complicated case of parapneumonic effusion or empyema.
How Is a Tube Thoracostomy Placed?
Tube thoracostomy can be done mainly by two principal methods, namely, the blunt dissection technique and the trocar technique. The trocar technique has a higher rate of intrathoracic organ injury. A combination of both the trocar technique and blunt dissection technique has been seen.
What Equipments Are Required for Tube Thoracostomy?
The types of equipment that are necessary for tube thoracostomy comprise a sterile set of instruments, a local anesthetic solution, suture material for tube fixation, a chest tube or catheter, a collection device, which can be a water seal (or dry equivalent), and dressings. No monitoring, oxygen, specialized personnel, or dedicated space is required unless needed for other aspects of the patient’s condition.
What Are the Complications of Tube Thoracostomy?
Some of the frequently observed complications of tube thoracostomy are:
1. Tube Malposition:
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It is the most occurring complication of tube thoracostomy. These are seen frequently when tubes are placed under suboptimal conditions and in urgent tube thoracostomy. Trocar technique of chest tube insertion is seen to increase the risk of tube malposition when compared with blunt dissection techniques.
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Complication rates of tube thoracostomy are more seen in severely ill patients, with approximately 21 percent of tubes inserted intra-fissurally and 9 percent intraparenchymally.
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Tube malposition is detected by performing CT (computed tomography), and confirmation in four locations namely intraparenchymal, fissural, extrathoracic, and angulation of the drainage in the pleural space is achieved. In this context, tube malposition is categorized as intraparenchymal tube placement, fissural tube placement, chest wall tube placement, mediastinal tube placement, and abdominal tube placement.
2. Esophageal Injury:
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Esophageal injury linked with TT is rarely seen to occur. Direct injury to the esophagus might be seen to occur while or after tube insertion. Drainage of enteric or salivary contents via the tube raises suspicion and contrast studies are done for the confirmation of the diagnosis. Esophageal injuries are avoided in the best manner by repositioning chest tubes that appear to end close to the mediastinum. Esophageal injuries associated with TT can be managed by general principles of esophageal injury management.
3. Gastric Injury:
The stomach is less frequently seen to get affected by the TT placement and usually occurs due to intra-abdominal placement (might also be associated with concurrent diaphragm injury). The use of proper methods and avoidance of trocar reduces the risk of this complication up to an extent. Gastric trauma at the time of TT insertion has also been observed in patients with intrathoracic gastric herniation. The presentation of gastrothorax might resemble a tension pneumothorax, increasing the risk of gastric TT placement. While chest radiographs might help prevent this complication, < 40 percent of patients have radiographs that are suggestive of diaphragm rupture.
4. Splenic Injury:
The proximity of the spleen is close to the left hemidiaphragm, which places the spleen at risk for injury if a TT is placed through or below the diaphragm. However, splenic placement rarely results in hemoperitoneum or shock. At times, it might be found incidentally on follow-up imaging. While splenic injuries can generally be managed non-operatively, patients with splenic injury from TT warrant an exploratory laparotomy to evaluate the extent of the injury and to rule out any potential associated injuries. The extent of the injury determines whether a splenectomy is required or not.
5. Diaphragmatic Injury:
Many of the diaphragmatic injuries during TT adjustment cause either laceration, perforation, or dysfunction of the muscle. Diaphragmatic laceration or perforation takes place when the tip of the trocar or the distal portion of the tube comes in contact with the diaphragm. Various conditions might increase the risk of this complication.
Conclusion:
Tube thoracostomy is a process of placement of a tube to eliminate extra fluid or air present in the pleural spaces. It can be incorporated in both chronic cases and emergencies. Some of the cases that require tube thoracostomy are emphysema, pleural effusion, lung infections, and more. It is done not without risk. The blunt dissection technique has a lower risk of complications and is hence recommended. Some of the complications can lead to diaphragm injury, gastric injury, thoracic injury, etc. It is important to keep the aspect of safety in mind to limit these errors. Most of these complications are preventable, and when they occur, they must be adequately and correctly managed.
