SPECIAL PROCEDURES
TUBE THORACOSTOMY (CHEST TUBE)
Definition:
It is the insertion of a tube into the pleural space through
a small incision.
Indications:
Chest tube insertion and drainage is commonly used:
1. For spontaneous or traumatic pneumothorax involving
> 25% collapse or enlargement, especially if it causes
respiratory distress or a serious gas exchange
abnormality;
2. For massive or recurrent benign pleural effusions not
responding to thoracentesis;
3. For empyema;
4. For hemothorax; and
5. For malignant effusions (before intrapleural
chemotherapy and/or sclerosing agents are used and
briefly afterward, to drain the weeping pleura).
Sometimes, loculated empyemas (Pus in a body cavity)
are effectively treated by instilling fibrinolytic agents into
the pleural space through the chest tube, thus avoiding
surgical lysis of the loculations
In patients with clotting abnormalities, tube thoracostomy
drainage may be necessary for the above indications, but
special care must be taken.
Procedure:
For pneumothorax, the tube is usually inserted in the
anterior 2nd or 3rd intercostal space at the midclavicular
line and is directed toward the apex of the lung.
For pleural effusions and other fluids in the thorax, the
tube is inserted in the midaxillary line of the 5th or 6th
intercostal space and is directed posteriorly.
Tubes for loculated effusions or empyemas are positioned
as required.
Lidocaine is used as for thoracentesis
A purse-string suture is made around the skin incision.
After the subcutaneous tissue and intercostal muscles are
separated with a clamp down to the parietal pleura, the
tube is introduced through the parietal pleura, preferably
with a clamp grasping the tip.
The tip is introduced into the pleural space and directed
as described above.
The purse-string suture is closed, and the tube is sutured
to the chest wall.
The tube is connected to simple underwater drainage (for
effusions or empyema) or placed in line with a negative
suction pump.
In some cases, pneumothoraces can be reinflated without
suction using a one-way Heimlich valve.
A chest x-ray is obtained after tube insertion to check the
tube's position and function.
When the situation resolves, the tube is removed.
If pneumothorax was the reason for insertion, the tube is
clamped for several hours before removal, and before the
tube is removed, a chest x-ray is obtained to verify that
the pleural leak has stopped.
For patients receiving ventilatory support with positive
pressure, the tube is often left in place until weaning is
accomplished.
More than one chest tube is sometimes required.
For pleural effusions, a small-bore chest tube or pigtail
catheter is usually placed and fluid is removed by
negative suction until the drainage is under 100mL per 24
hours and the lung has expanded
Complications:
Include hemorrhage from intercostal vessel injury,
Subcutaneous emphysema,
Injury due to a malpositioned tube (e.g. into the major
fissure, and occasionally into the lung), and
Local infection or pain
Reexpansion pulmonary edema due to increased capillary
permeability may occur in the reexpanded lung, especially
after prolonged lung collapse and rapid reinflation.
Tube insertion may be difficult because of adhesions or a
very thick pleura
Other problems include inadequate drainage of the pleural
space due to clots or gelatinous inflammatory material
and plugging or kinking of the tube.
THORACOTOMY
Definition:
Incision through the chest wall into the pleural space.
Indications
Thoracotomy for open biopsy of lung, pleura, hilum, and
mediastinum is the diagnostic gold standard to which all
other procedures must be compared.
Exploratory thoracotomy is required in < 10% of cases to
establish the diagnosis and resectability of lung cancer.
Thoracotomy is most helpful in patients with undiagnosed
focal or diffuse pulmonary problems, in which definitive
diagnosis is likely to improve the management plan.
It is used in patients with pulmonary problems of unknown
etiology when less invasive procedures have not yielded a
diagnosis or when other procedures are more dangerous
or unlikely to yield a diagnosis.
An emergent thoracotomy may be necessary to repair a
traumatic aortic disruption
Contraindications:
Include unstable systemic status (e.g. cardiopulmonary,
nutritional, metabolic, renal), i.e. inability to tolerate the
injury of major surgery.
Procedure:
Three basic approaches are used.
Each requires a general anesthetic in an operating room.
1. In limited anterior or lateral thoracotomy, a 6- to
8-cm intercostal incision is made; after a large tidal
volume, the lung is popped out to be biopsied through
the incision. When this approach is used to diagnose
diffuse interstitial lung disease, localized peripheral
lung disease, or infectious diseases in
immunosuppressed hosts, morbidity and mortality are
very low. Patients require a chest tube for 24 to 48 h
and can often leave the hospital in 3 to 4 days.
2. Full wide incision thoracotomy gives access to
pleura, hilum, mediastinum, and the entire lung. It is
most useful when a neoplasm is suspected or when
multiple sites in one lung require biopsy.
3. Median sternotomy is used when lesions in both
lungs require biopsy.
Complications
Are greater than those for any other pulmonary biopsy
procedure because of the risks of general anesthesia,
surgical trauma, and a longer hospitalization with more
postoperative discomfort.
Hemorrhage, infection, pneumothorax, bronchopleural
fistula, and reactions to anesthetics are the greatest
hazards.
