A tube thoracostomy is the placement of a tube through the thoracic
wall and into the pleural cavity. It is commonly referred to as
a chest tube. It is placed in order to evacuate air, blood, or other fluid
that collects within the pleural space. The etiology of the air
or fluid collections can be due to iatrogenic complications, infection,
lung disease, malignancy, or trauma.
Thoracic trauma continues to account for nearly one-quarter of
all trauma-related mortality.1,2 Although some injuries
require surgical intervention, the majority may be treated nonoperatively. Injuries
to the chest wall, lung, trachea, bronchi, or esophagus may lead
to the presence of abnormal air and/or fluid in the pleural
space. The use of a tube thoracostomy (chest tube) in these situations
may be both diagnostic and therapeutic. Historically, closed-tube
drainage of the pleura has been used for various indications for
more than a century.3 This chapter deals primarily with
the use of tube thoracostomy following trauma.
On inspiration, the diaphragm and accessory muscles of respiration
contract and generate negative pressure within the pleural space.
Penetration of the visceral or parietal pleura due to injury disrupts
this pressure gradient and allows air to enter the “potential
space” between the parietal and visceral pleurae, resulting
in a pneumothorax.1,2A simple
pneumothorax is the accumulation of air that is not under pressure
within the pleural space. It may cause the ipsilateral lung
to collapse. As air continues to accumulate and if there are no adhesions,
the increased pressure in the thoracic cavity may push the mediastinum
toward the noninjured side. This can cause angulation of the atriocaval
junction, impairment of atrial filling, and a subsequent decrease
in cardiac output manifest by hypotension. The
presence of a pneumothorax under pressure accompanied by respiratory
and/or circulatory compromise is termed a tension pneumothorax
and is an immediate life threat.
There are two important points to remember
about a tension pneumothorax. First, it is a clinical diagnosis
based on the patient’s presenting signs and symptoms. Do
not wait for a chest film to establish the diagnosis. Second, the
initial treatment of this entity is needle decompression followed
by tube thoracostomy. A large-bore needle is inserted in the
second intercostal space in the midclavicular line at the superior
border of the rib. If the patient has a tension pneumothorax, a
gush of air will ensue and the patient’s symptoms will
improve. Thus, the tension pneumothorax is converted to a simple pneumothorax
and a chest tube may be inserted for more definitive management.
Refer to Chapter 27 for complete details regarding the needle thoracostomy
An open pneumothorax is caused by a
traumatic chest wall injury that results in a defect that is greater
than or equal to two-thirds the diameter of the patient’s
trachea. Air passes via the path of least resistance (the defect)
and leads to equilibration of the intra- and extrathoracic ...