Chapter 28

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 procedure.

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 ...

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