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Background Tube thoracostomy (TT) allows for the drainage of air or fluid from the pleural space. We aimed to describe the indications, management, and outcomes of patients managed with TT at AIC Litein Hospital in Southwestern Kenya. Methods This prospective study was undertaken between November 2020 and August 2022. All consecutive patients with TT were included. Data were collected on demographics, presentation, indications for TT, management, and outcome. Ethical approval was obtained from the Institutional Ethics and Research Committee. Results The study included 39 (33 male, 6 female) patients who had a mean age of 35 years (range 3-75) and 45 TTs placed for a median duration of 6 days (1-26). Hemopneumothorax (n=19), empyema thoracis (n=8), and pneumothorax (n=7) were the most common indications for TT. Trauma was noted in 28 cases presenting as assault (n=17), road traffic collision (n=8), fall (n=1), and barotrauma (n=1). Preadmission traumatic injuries led to four deaths, while fourteen (35.9%) patients developed TT-related complications, with three requiring TT replacement. Conclusions In this series, TT was mainly indicated for hemopneumothorax, empyema thoracis, and pneumothorax. [ABSTRACT FROM AUTHOR]

Use of routine chest x-rays (CXR) following thoracostomy tube (TT) removal is highly variable and its utility is debated. We hypothesize that routine post-pull chest x-ray (PP-CXR) findings following TT removal in pediatric trauma would not guide the decision for TT reinsertion. Patients ≤ 18 y who were not mechanically ventilated and undergoing final TT removal for a traumatic hemothorax (HTX) and/or pneumothorax (PTX) at a level I pediatric trauma center from 2010 to 2020 were retrospectively reviewed. The outcomes of interest were rate of PP-CXR and TT reinsertion rate following PP-CXR. Clinical predictors for worsened findings on PP-CXR were also assessed. Fifty-nine patients were included. A CXR after TT removal was performed in 57 patients (97%), with 28% demonstrating worsened CXR findings compared to the prior film. Except for higher ISS (p = 0.033), there were no demographic or clinical predictors for worsened CXR findings. However, they were more likely to have additional films following the TT removal (p = 0.008) than those with stable or improved PP-CXR findings. One (1.8%) asymptomatic child with worsened PP-CXR findings had TT reinsertion based purely on their worsened PP-CXR findings. The vast majority of PP-CXR did not guide TT reinsertion after pediatric thoracic trauma. Treatment algorithms may aid to reduce variability and potentially unnecessary routine films. [ABSTRACT FROM AUTHOR]

Abstract Primary spontaneous pneumothorax (PSP) is a relatively common problem in emergency medicine. The incidence of PSP peaks in adolescence and is most common in tall, thin males. Recent advances in the care of patients with PSP have called into question traditional approaches to management. This clinical review highlights the changing management strategies for PSP and concludes with a proposed evidence‐based pathway to guide the care of adolescents with PSP.

OBJECTIVES Open in new tab Download slide Open in new tab Download slide Severe acute respiratory syndrome coronavirus 2, a novel coronavirus, affects mainly the pulmonary parenchyma and produces significant morbidity and mortality. During the pandemic, several complications have been shown to be associated with coronavirus disease 2019 (COVID-19). Our goal was to present a series of patients with COVID-19 who underwent chest tube placements due to the development of pleural complications and to make suggestions for the insertion and follow-up management of the chest tube. METHODS We retrospectively collected and analysed data on patients with laboratory-confirmed COVID-19 in our hospital between 11 March and 15 May 2020. Patients from this patient group who developed pleural complications requiring chest tube insertion were included in the study. RESULTS A total of 542 patients who were suspected of having COVID-19 were hospitalized. The presence of severe acute respiratory syndrome coronavirus 2 was confirmed with laboratory tests in 342 patients between 11 March and 15 May 2020 in our centre. A chest tube was used in 13 (3.8%) of these patients. A high-efficiency particulate air filter mounted double-bottle technique was used to prevent viral transmission. CONCLUSIONS In patients with COVID-19, the chest tube can be applied in cases with disease or treatment-related pleural complications. Our case series comprised a small group of patients, which is one of its limitations. Still, our main goal was to present our experience with patients with pleural complications and describe a new drainage technique to prevent viral transmission during chest tube application and follow-up. [ABSTRACT FROM AUTHOR]

Background: The need to evacuate the chest after a penetrating wound was first recognized in the 18th century. Most thoracic injuries are treated with tube thoracostomy (TT) which refers to the insertion of a TT into the pleural cavity to drain air, blood, pus, or other fluids. However, TT has been challenged in the trauma care due to insertional, positional, or infective complications. Methods: A retrospective study of all trauma patients who had TT insertion from 2008 to 2014 was conducted based on the trauma registry data to describe patient characteristics, injury characteristics, management, and outcomes. The complication incidences per TT before (2008) and after (2009–2014) the implementation of standard protocol were compared. Results: During the study period, 804 patients were managed with 1004 TT procedures. The mean age was 34 years, and majority (91%) was males. Motor vehicle crash (43%) was the main mechanism of injury. Mean injury severity score was 22. The rib fractures (68%) were more frequent followed by pneumothorax (49%). Nearly 72% of patients received antibiotic coverage before insertion. The complications developed per TT reduced over the years from 2008 to 2014 (12.6% to 4.4%). The average complication per TT after the protocol implementation (2009–2014) reduced by 7% when compared to the duration before implementation (2008). Conclusions: The present study shows that standardized management of trauma patients who undergo TT results in a reduction in complications, helps improve patient flow, and ensures the proper management of resources in our high-volume trauma center. [ABSTRACT FROM AUTHOR]

One of the potential complications of acupuncture is pneumothorax, caused by the entry of the needle to the visceral pleura and damaging the lung parenchyma. Our patient suffered a bilateral pneumothorax and sudden respiratory failure. Our intention in this study is to offer a reminder of this rare and life threatening complication with this case report. A 51-year-old male patient presented to the emergency department with dyspnea after acupuncture treatment at a hotel spa center. A physical examination revealed no respiratory sound in either lung. A chest X-ray revealed a bilateral pneumothorax. The patient was treated with a bilateral tube thoracostomy. [ABSTRACT FROM AUTHOR]

Placement of a chest tube drains intrapleural fluid and air. The tube should be attached to a drainage system, such as one-, two-, or three-compartment devices, a one-way (Heimlich) valve for ambulatory drainage, a digital system, or a vacuum bottle. The frequently employed three-compartment systems, currently integrated disposable units, allow adjustment of negative pressure or no suction (water seal), and include an air leak meter on the water seal chamber to be used for demonstrating and quantifying air leak. These readings are subjective and prone to interobserver variability. Digital pleural drainage systems offer the benefits of quantification of any air leak and pleural pressure. Indwelling pleural catheters, typically utilized for malignant pleural effusion, can be drained using vacuum bottles. Knowledge of the design and functionality of each device in the setting of an individual patient's specific pleural process facilitates the selection of practical and financially prudent chest tube drainage strategies. [ABSTRACT FROM AUTHOR]

Introduction Chest injuries occur in a significant portion of trauma patients and hemothorax is a common result. While the initial management of traumatic hemothorax is most commonly treated with tube thoracostomy, the management of retained hemothorax is a subject of debate. Recent literature has proposed different methods for treating or preventing retained hemothorax, yet the approach to this pathology is not straightforward. Methods The literature was reviewed for relevant studies regarding the prevention and management of post-traumatic retained hemothorax. What follows is a review of the recent literature and an algorithm for the approach to treating a traumatic retained hemothorax. Results Identifying a traumatic retained hemothorax and preventing subsequent complications such as pneumonia, empyema, and fibrothorax are significant issues faced by surgeons. Studies for preventing retained hemothorax have focused on initial chest tube size, location, and peri-procedural placement conditions, as well as thoracic lavage. Several treatment modalities exist, including second drainage procedure and intra-pleural fibrinolytic drug instillation, but video-assisted thoracoscopic surgery is the most common and successful approach. Regardless of the approach to evacuation, early intervention is paramount. Conclusion Further studies will help characterize appropriate candidates, timing, treatment modalities, and guide therapy for retained hemothorax. [ABSTRACT FROM AUTHOR]

Purpose: Tube thoracostomy is frequently used in thoracic trauma patients. However, there is no consensus on whether low pressure suction or water seal is the optimal method of tube management. Against this background, we performed a systematic review of studies comparing suction and water seal management of chest tubes placed for traumatic chest injuries in adults. Evaluated outcomes are duration of chest tube treatment, length of stay in hospital, incidence of persistent air leak, clotted hemothorax, and the need for (re-)interventions.Methods: A systematic literature search according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines was performed. Included studies were evaluated according to the Cochrane Collaboration’s tool for assessing the risk of bias, and according to Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines for assessing the quality of evidence.Results: After assessment of 120 identified studies, three RCT’s (randomized controlled trials) were included in this review and meta-analysis. A favorable effect of suction was found for duration of chest tube treatment [MD (mean difference) − 3.38 days, P = 0.005], length of stay in hospital (MD −3.90 days, P = 0.0003), and the incidence of persistent air leak [OR (odds ratio) 0.27, P = 0.001]. No significant difference was found for the incidence of clotted hemothorax and (re-)interventions. The quality of evidence according to GRADE was low, except for persistent air leak (moderate).Conclusions: Suction seems to have a positive effect on duration of chest tube treatment, length of stay in hospital and persistent air leakage in chest trauma. However, available data was limited and the quality of evidence was (very) low to moderate according to GRADE. [ABSTRACT FROM AUTHOR]

Introduction: Tube thoracostomy is an important treatment for traumatic hemothorax and pneumothorax. The optimal tube diameter remains unclear. To reduce invasiveness, we use small-bore chest tubes (≤20 Fr) for all trauma patients for whom tube thoracostomy is indicated in our emergency department (ED). The aim of this study was to investigate the effectiveness and safety of small-bore tube thoracostomy for traumatic hemothorax or pneumothorax.Method: We conducted a retrospective observational study at a single emergency medical center. This study included adult patients (≥18 years old) who had undergone tube thoracostomy for chest trauma in the ED during the 5 years from October 2013 to September 2018. We used 20 Fr chest tubes or 8 Fr pigtail catheters. The examined outcome was tube-related complications, such as tube obstruction, retained hemothorax, and unresolved pneumothorax.Results: A total of 107 tube thoracostomies were performed in 102 patients. The mean Injury Severity Score of these patients was 17.8 (±9.6), and the mean duration of the tube placement period was 3.9 days (±1.8). Eight patients developed tube-related complications (7.8%) (retained hemothorax: 4 patients (3.9%), unresolved pneumothorax: 4 patients (3.9%)). None of these cases were caused by tube obstruction. Although the drainage itself was effective, they underwent definitive invasive interventions to stop bleeding or air leak.Conclusion: Our study showed that the use of small-bore (≤20 Fr) chest tubes to treat traumatic hemothorax/pneumothorax achieved the purposes of tube thoracostomy. It might be possible to safely manage chest trauma with small-bore chest tubes. [ABSTRACT FROM AUTHOR]

Background: Chest tube drainage is a common procedure performed by physicians in the emergency setting. Complications may arise in up to 25% of the cases. These vary from drain misplacement to lethal iatrogenic injuries. Ultrasound provides adequate visualization and correct identification of the insertion site, allows the exclusion of a vulnerable intercostal artery, and enables timely diagnosis of drain malpositioning. Although feasible, ultrasound-guided techniques are underused and seldom applied during chest drainage. One reason for that is the lack of a comprehensive step-by-step description incorporating these techniques. This article aims to describe a standardized ultrasound-guided chest tube drainage technique, and also review the evidence supporting its potential benefits.Materials and Methods: we conducted a thorough literature search on ultrasound techniques regarding the identification of the diaphragm, the neurovascular intercostal bundle, and the position of the chest drain. Also, we analyzed published articles about complications of chest drainage.Results: we propose a feasible step-by-step ultrasound-guided technique of chest drainage and discuss why this technique should be incorporated in the routine practice.Conclusion: ultrasound guidance should be incorporated in chest drainage in a stepwise fashion. Although intuitively safer, future randomized studies are warranted to support this technique. [ABSTRACT FROM AUTHOR]

Objectives: Tube thoracostomy (TT) is a common yet potentially life-saving trauma procedure. After successful placement however, securing a TT through suturing is a skillset that requires practice, risking that the TT may become dislodged during prehospital transport. The purpose of this study was to examine if the iTClamp was a simpler technique with equivalent effectiveness for securing TTs. Materials and methods: In a cadaver model, a 1.5 inch incision was utilized along the upper border of the rib below the 5th intercostal space at the anterior axillary line. TTs (sizes 28Fr, 32Fr, 36Fr and 40Fr) were inserted and secured with both suturing and iTClamp techniques according to the preset randomization. TT were then functionally tested for positive and negative pressure as well as the force required to remove the TT (pull test-up to 5 lbs). Time to secure the TT was also recorded. Results: When sutured is placed by a trained surgeon, the sutures and iTClamp were functionally equivalent for holding a positive and negative pressure. Mean pull force for both sutures and iTClamp exceeded the 5 lb threshold; there was no significant difference between the groups. Securing the TT with the iTClamp was significantly faster (p < 0.0001) with the iTClamp having a mean application time of 37.0 ± 22.8 s and using a suture had a man application time of 96.3 ± 29.0 s. Conclusion: The iTClamp was effective in securing TTs. The main benefit to the iTClamp is that minimal skill is required to adequately secure a TT to ensure that it does not become dislodged during transport to a trauma center. [ABSTRACT FROM AUTHOR]

Chest tube thoracostomy is a simple life-saving procedure with many benefits but comes with significant potential morbidity. Potentially all intra-thoracic organs are at risk of possible injury as well as peritoneal. We present four patients who had chest tube thoracostomy with potential complications fortunately were managed promptly and recovered fully. Complications related to tube thoracostomy is reported up to 25 % especially when done under emergency conditions. While the procedure is reported safe, it's associated morbidity is not well described. Additionally, clinicians are urged to follow standard operating procedures and address the potential complications with consent to their patients. Chest tube thoracostomy is an invasive life-saving procedure performed across various clinical ranks and sub-specialties. It has potential life-threatening risks and complications therefore clinicians should be well trained to identify such complications and address accordingly. • Chest tube thoracostomy is one of the most common life-saving invasive procedure performed. • Due to its invasive nature, it comes with potential risks and complications. • Clinicians are urged to understand the risks and to address them to the patients. • Clinicians should be trained on the proper placement techniques and evaluation of chest tube thoracostomy system. [ABSTRACT FROM AUTHOR]

Introduction: Tube thoracostomy (TT) is a lifesaving procedure for a variety of thoracic pathologies. The most commonly utilized method for placement involves open dissection and blind insertion. Image guided placement is commonly utilized but is limited by an inability to see distal placement location. Unfortunately, TT is not without complications. We aim to demonstrate the feasibility of a disposable device to allow for visually directed TT placement compared to the standard of care in a large animal model.Methods: Three swine were sequentially orotracheally intubated and anesthetized. TT was conducted utilizing a novel visualization device, tube thoracostomy visual trocar (TTVT) and standard of care (open technique). Position of the TT in the chest cavity were recorded using direct thoracoscopic inspection and radiographic imaging with the operator blinded to results. Complications were evaluated using a validated complication grading system. Standard descriptive statistical analyses were performed.Results: Thirty TT were placed, 15 using TTVT technique, 15 using standard of care open technique. All of the TT placed using TTVT were without complication and in optimal position. Conversely, 27% of TT placed using standard of care open technique resulted in complications. Necropsy revealed no injury to intrathoracic organs.Conclusion: Visual directed TT placement using TTVT is feasible and non-inferior to the standard of care in a large animal model. This improvement in instrumentation has the potential to greatly improve the safety of TT. Further study in humans is required.Level Of Evidence: Therapeutic Level II. [ABSTRACT FROM AUTHOR]

Purpose: Postoperative pneumothorax and effusion remain a concern following congenital diaphragmatic hernia (CDH) repair. Despite a recent trend away from intraoperative thoracostomy, few studies have actually compared outcomes with and without a chest tube. Rationale commonly cited for the more minimalistic approach include the presumed low likelihood of postoperative complications, potential risk of patch infection, and prolonged intubation. We evaluate these theories, as well as the implications of intraoperative chest tube (IOCT) placement.Methods: We performed a retrospective chart review of 174 patients who underwent CDH repair at our academic children's hospital from 2004 to 2015. We compared incidence of clinically significant pleural events between patients who received an IOCT (n = 49) and those who did not (NIOCT, n = 124). We also evaluated time to extubation and rate of patch infections.Results: Clinically significant pneumothorax or effusion occurred in 28% of NIOCT patients versus 10% of IOCT patients (P = .01). After thoracoscopic repair, time to extubation averaged 5.2 days in IOCT patients, 5.4 days in NIOCT patients with no postoperative complications, and 6.4 days in NIOCT patients requiring postoperative intervention. After open repair, time to extubation averaged 13.8, 13.6, and 22.5 days, respectively. There were no documented patch infections.Conclusions: Chest tube placement during CDH repair is associated with significantly lower incidence of clinically significant pleural complications, does not delay extubation, and results in shorter ventilator times than cases that require postoperative intervention. Patch infections are extremely rare. There is no evidence that chest tube placement increases this risk. [ABSTRACT FROM AUTHOR]

Introduction: Chest decompression can be performed by different techniques, like needle thoracocentesis (NT), lateral thoracostomy (LT), or tube thoracostomy (TT). The aim of this study was to report the incidence of prehospital chest decompression and to analyse the effectiveness of these techniques.Material and Methods: In this retrospective case series study, all medical records of adult trauma patients undergoing prehospital chest decompression and admitted to the resuscitation area of a level-1 trauma center between 2009 and 2015 were reviewed and analysed. Only descriptive statistics were applied.Results: In a 6-year period 24 of 2261 (1.1%) trauma patients had prehospital chest decompression. Seventeen patients had NT, six patients TT, one patient NT as well as TT, and no patients had LT. Prehospital successful release of a tension pneumothorax was reported by the paramedics in 83% (5/6) with TT, whereas NT was effective in 18% only (3/17). In five CT scans all thoracocentesis needles were either removed or extrapleural, one patient had a tension pneumothorax, and two patients had no pneumothorax. No NT or TT related complications were reported during hospitalization.Conclusion: Prehospital NT or TT is infrequently attempted in trauma patients. Especially NT is associated with a high failure rate of more than 80%, potentially due to an inadequate ratio between chest wall thickness and catheter length as previously published as well as a possible different pathophysiological cause of respiratory distress. Therefore, TT may be considered already in the prehospital setting to retain sufficient pleural decompression upon admission. [ABSTRACT FROM AUTHOR]

Background A link between childhood radiation and future cancer risks exists, and reduction of unnecessary radiation in childhood has been recommended. Pneumothoraces, pleural effusions, and many surgical procedures require placement of a chest tube/pigtail catheter. Traditional management is daily x-rays, with an x-ray after tube removal. Our hypothesis is the “post pull” x-ray rarely results in changing clinical management of the patient. Methods With IRB approval, a 5-year retrospective chart review was performed. Inclusion criteria were chest tube or pigtail placed for any reason with complete records. Data collected were demographics, reason for and duration of placement, number of x-rays done prior to and after removal. Primary outcome was whether the “post pull” x-ray changed clinical management. Results A total of 179 episodes were evaluated. Seventeen were excluded for incomplete data, or death/transfer of the patient with the tube in situ. Forty-nine tubes/pigtails were placed for pneumothorax, 48 for pleural effusion/empyema, 9 for hemothorax, and 51 during operative procedure. A median of 5 x-rays was done post insertion. 99% of the patients (160/162) had a “post pull” x-ray performed after tube removal. In 9 cases the x-ray changed patient management. Conclusions X-ray after chest tube/pigtail removal rarely changes patient management. We recommend considering imaging if there are clinical symptoms. Level of evidence Prognosis study, level II (retrospective cohort) [ABSTRACT FROM AUTHOR]

Closed chest drainage has been performed since 1800s and has arrived to date by keeping its importance, without too much change in its principals. Chest drainage systems provide one way evacuation of free air and/or fluid accumulated in the pleural cavity due to various aetiologies. Tube thoracostomy is simple but life saving procedure in states of emergency. In the proper indication, it provides a dramatical attenuation in the acute symptoms of illness. Tube thoracostomy provides a safe and effective drainage when performed according to the proper surgical principals. On the other hand, lethal complications may occur during and after tube thoracostomy. Therefore, a thorough knowledge regarding the indications, technical principals, and management of tube thoracostomy would be helpful for understanding the basic applications that prevent complications a priori. [ABSTRACT FROM AUTHOR]

Abstract: Background: Definitive practice guidelines regarding the utility of chest x-ray (CXR) following chest tube removal in trauma patients have not been established. The authors hypothesized that the selective use of CXR following chest tube removal is safe and cost effective. Methods: A retrospective review of chest tube insertions performed at a level I trauma center was conducted. Results: Patients who underwent chest tube removal without subsequent CXR had a lower mean Injury Severity Score and were less likely to have suffered penetrating thoracic injuries. These patients received fewer total CXRs and had shorter durations of chest tube therapy and shorter lengths of stay following tube removal. Subsequent reinterventions were performed more frequently in the CXR group. The annual decrease in hospital charges by foregoing a CXR was $16,280. Conclusions: The selective omission of CXR following chest tube removal in less severely injured, nonventilated patients does not adversely affect outcomes or increase reintervention rates. Avoiding unnecessary routine CXR after chest tube removal could provide a significant reduction in total hospital charges. [Copyright &y& Elsevier]