Chest tube thoracostomy: A simple life-saving procedure with potential hazardous risks

Abstract

Introduction and importance

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.

Case presentation

We present four patients who had chest tube thoracostomy with potential complications fortunately were managed promptly and recovered fully.

Clinical discussion

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.

Conclusion

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.

Highlights

• •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.

1. Introduction

Chest tube thoracostomy is one of the most common procedures done in routine clinical practice by clinicians of different ranks and sub-specialties [1]. Chest tube insertion has been classified as a compulsory life-saving procedure for clinicians but unfortunately it carries a significant preventable morbidity [1,2]. Thoracic injury accounts for 25 % of all trauma deaths. Thoracic trauma is commonly managed by tube thoracostomy with an overall complication rate of up to 30 % among all operators [2]. Complications associated related chest tube thoracostomy can be categorized into insertional, positional or infective [3]. The technique of chest tube thoracostomy has changed over time since its first description by Hippocrates however the eventual goal of draining the pleural cavity has remained the same [2]. Clinicians should understand safe and reliable techniques to avoid serious complications [4]. Herein we present four cases of morbidity associated with chest tube thoracostomy and to emphasize patient safety and error prevention.

This work has been reported in line with the PROCESS 2020 criteria [5].

2. Case presentation

2.1. Case 1

A 56-year-old male, known diabetic on regular oral medications, sustained polytrauma to the head, chest and left leg after being involved in a road traffic accident. He presented with a frontal headache but no history of loss of consciousness nor vomiting with moderate chest pain associated with coughing. He was then rushed in a nearby health facility where he received first aid then referred to our centre for further care. On presentation he was alert with a Glasgow coma scale (GCS) of 15/15, his pupils were equal, symmetrical and reacting to light. He was dyspneic and saturating at 87 % on room air and 95 % on 5 l of oxygen per minute. The left leg was swollen, warm and crepitus was felt on palpating the tibia hence was immediately splinted. His blood pressure was 110/78 mmHg, a pulse rate of 100 bpm and axillary temperature of 37 °C. His random blood glucose read “high” and had ketones in urine and was kept on DKA protocol.

On his respiratory examination, his trachea was deviated mildly to the right, had bilateral air entry however with reduced breath sounds bilaterally on the lower zones. A plain chest radiograph was immediately taken which revealed bilateral lung contusions and left sided 6th, 7th and 8th rib fractures and a chest tube was placed in the left side by general surgery trainee that drained 200mls of hemorrhagic fluid (Fig. 1).

Fig. 1.

Plain chest X-ray showing bilateral lung contusions, trachea centrally located (blue arrow) and left sided chest tube (red arrow). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

His CBC had a normal white cell count with a hemoglobin of 11.7 g/dl. His serum electrolytes, urea and creatinine were within normal range. He faired well in the ICU however control chest X-ray revealed no hemothorax but the chest-tube was seen perforating the left hemidiaphragm (Fig. 1). The chest-tube was removed and was monitored closely for five days whereby his vitals maintained within normal limits, had bilateral good air entry on auscultation and was saturating at 98 % on room air. His left leg was casted by the orthopedic team for the closed mid-tibia fracture and his blood glucose has normalized with insulin.

Patient was discharged and was reviewed two weeks later with no chest symptoms with normal respiratory and abdominal exam. He was then discharged to continue follow up at orthopedic and diabetes clinics.

2.2. Case 2

A 61-year-old male presented to our emergency unit with a 19-hour history of head, chest and abdominal trauma following a motor traffic accident. The exact mechanism of injury was unknown and was brought in a confused state. He had a history of loss of consciousness following the event for a brief period of time and had no bleeding per ears nose or throat.

On examination, he was dyspnic and saturating at 85 % on room air and 96 % on 3 l of oxygen per minute. He was mildly pale with a GCS of 14/15, blood pressure of 80/70mmhg, pulse rate of 120 bpm and axillary temperature of 36 °C. An immediate eFAST scan was done which was positive for right hemothorax and hemo-peritoneum. A chest tube was inserted in the right side by the surgical trainee on duty which drained approximately 500mls of hemorrhagic fluid.

His CBC had a normal leucocyte count of 6.72 × 10⁹/l, hemoglobin of 11.6 g/dl and a platelet count of 128 × 10⁹/l. His serum potassium was 3.6 mmol/L, serum sodium of 135.90 mmol/l and blood group of O Rh-positive. He was then taken for a chest X-ray which revealed bilateral lung contusions and a chest tube at the mediastinum (Fig. 2). CT-scan of the brain revealed cerebral edema with no extra-axial collections. He was immediately planned for a laparotomy which revealed hemoperitoneum of approximately 1 l, a lacerated liver at segment five which was repaired and the chest-tube was revised by the general surgeon on call. He was then sent to the general ward for monitoring.

Fig. 2.

A: Plain chest X-ray showing bilateral traumatic lung contusions, B-C: chest X-ray showing the chest tube deep inside the thoracic cavity coursing towards the mediastinum.

During his stay he faired well and control chest X-ray was normal hence chest tube was removed. He recovered well with no abdominal and nervous system symptoms. He was then discharged and seen at the outpatient clinic with no new complaints and the sutures were then removed.

2.3. Case 3

A 66-year-old male, known hypertensive with hypertensive heart disease and cerebrovascular accident was admitted to our centre with a two-week history of chest tightness, difficulty in breathing and dry cough. Upon examination, he was fully conscious and alert, mildly pale, dyspneic with blood pressure of 90/60 mmHg, pulse rate of 56 beats/min and saturating at 92 % on room air and 96 % on 2 l of oxygen. His lab results revealed hemoglobin of 12 g/dl, white cell count of 5.72 × 10⁹/l and normal platelet count of 194 × 10⁹/l. His serum creatinine was 129 μmol/l and serum urea of 4.63 mmol/l.

A chest X-ray was done that revealed a right-sided pleural effusion hence a chest tube was inserted (Fig. 3). Approximately 1.5 l of straw-colored fluid was drained and was monitored for one week until gradual output to nil. Control chest X-ray revealed no pleural effusion with right subcutaneous emphysema and tip of the chest tube behind the pericardium and through the diaphragm (Fig. 4). Chest CT-scan was done which revealed chest tube posterior to the right pericardial wall (Fig. 5). The chest tube was then removed and patient was managed conservatively. He was kept on furosemide and digoxin then discharged. Upon follow up after 3 weeks he had normal respiratory examination with no symptoms.

Fig. 3.

Plain chest X-ray showing right sided pleural effusion.

Fig. 4.

Control chest X-ray showing malpositioned chest tube with the tip piercing the diaphragm (red arrow) and right subcutaneous emphysema (yellow arrow). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 5.

CT-scan showing course of the chest tube posterior to the right pericardial wall (red arrows). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

2.4. Case 4

An 18-year-old female presented with a three-week history of left sided chest pain and productive cough. She reported history of chest trauma from a fall prior to the onset of these symptoms. She was taken to a nearby health centre where a chest tube was inserted which drained pus and referred for further management. On initial presentation she was alert, mildly pale, dyspneic on oxygen saturating at 97 %, blood pressure of 127/70 mmHg and pulse of 100 beats/min. On respiratory examination a chest tube on the left side but no oscillation appreciated and whitish pus discharge seen around the chest tube insertion site. Trachea slightly deviated to the right side and no air entry with dull percussion note throughout the left side. Her CBC revealed leucocytosis of 13.7 × 10⁹/l, anaemia of 6.7 g/dl and thrombocytosis of 706 × 10⁹/l. Her serum creatinine was 42 μmol/l, urea of 3.57 mmol/l with potassium and sodium within normal range. The pus was tested negative for M. tuberculosis.

CT-scan of the chest revealed multiple loculations with a thickened pleura in the left hemithorax with the chest tube seen in the lung parenchyma (not in the loculation). A finding suggestive of a thoracic empyema with a misplaced chest tube (Fig. 6). Bilateral axillary and paratracheal lymphadenopathy observed with a moderate pericardial effusion was also noted. She was then transfused with two units of whole blood and control hemoglobin of 9.7 g/dl. The chest tube was then revised and irrigated. She is being managed with chest physiotherapy and draining approximately 100 mls of pus. She was also kept on intra-venous Gentamycin according to culture and sensitivity.

Fig. 6.

CT-scan showing multiple pus loculations in the right hemithorax (yellow arrows) with chest tube malpositioned within the lung parenchyma (red arrow). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

She was then taken for a thoracotomy by the consultant surgeon of which revealed multiple pus pockets, thick yellow pus in the parietal pleura, very thick parietal pleural layer adhered to the visceral pleura. Lung decortication was done, there were alveolar perforations, large one was repaired. Irrigation of the cavity was done with warm normal saline. UWSD kept in situ for drainage (air bubbles come out with pressure and minimal blood) and the chest wound closed in layers. She faired well in the wards for 10 days with chest physiotherapy, intravenous antibiotics and adequate analgesia. Thereafter she was discharged and attended our out-patient clinic for a follow up after 2 weeks with no complains, the thoracotomy wound had healed well and on respiratory examination, the trachea was central and bilateral air entry in both lung fields was noted on auscultation.

3. Discussion

Chest tube thoracostomies are among the most common invasive procedure performed across many clinical units; as an emergency and elective [4]. The nature being invasive comes with potential risks and complications. Clinicians are urged to understand the risks and address them to the clients. In this era of transparent information and value-based healthcare, robust and competent medical training enforcement enhances patient experience and satisfaction [4].

The overall complication rate of chest tube thoracostomy is up to 37 %, and it is reported that complications associated with tube thoracostomies increase length of hospital stay and increased hospitalization costs [6]. There are numerous complications of the procedure. Being an invasive procedure, pain is common from the parietal pleura therefore clinicians should administer adequate local analgesia and maintain throughout to achieve pain-free chest physiotherapy. Tube can also dislodge if they are not well secured or used inappropriate smaller sizes compared to the patient's body habitus [7].

The ultimate goal of chest tubes is to drain unwanted substances (blood, pus, fluid, air) from the pleural cavity therefore blockage is a potential risk therefore tube size selection is vital. Thick fluids like pus and blood require large bore tube, or even two tubes, whereas air and serous fluids of small amounts can be managed by smaller caliber tubes [8]. Other common complications are recurrent or residual pneumothorax, air leak and incorrect placement of the tube i.e., into the subcutaneous plane. Other less common complications as stated by Chan et al. are injury to intra-thoracic organs like esophagus, lungs and the atrium of the heart as seen in case 4 whereby the tube was mispositioned into the lung parenchyma [9]. The authors continue to state that the rate of complications was higher if the procedure was done under urgent or emergent conditions especially in the emergency unit [9]. This is evident from our series as 2 out of 4 cases were emergency, nonetheless such morbidity is preventable if proper training is offered and standard care and operating procedures are adhered regardless of the setting. Control plain chest X-ray can be done right after the procedure to confirm the placement of the chest-tube and to detect early any complications. This also includes timely patient follow up and reviewing the patient as a whole clinically; to check the patency of the underwater seal drain by its oscillation, a complete chest examination and this can be aided by a bedside chest ultrasonography. Ultrasonography can be done bedside in resource-limited settings like ours, poses no radiation risks, and can guide clinicians on the retained effusions.

Tube malposition is also a common morbidity and it is more common if placed in suboptimal and under emergent conditions and when used a trochar compared to blunt dissection technique. CT-scan can best define the malposition as seen in cases 3 and 4, compared to plain chest X-rays [10,11]. Chest tubes can be malpositioned into lung parenchyma, lung fissure or mediastinum, especially in pre-existing pleural conditions like adhesions. They can cause damage to pulmonary vessels and cause inadequate drainage hence should repositioned or replaced to improve outcome [10]. Tubes inserted far deep can reach the mediastinum and can injure the pericardium, esophagus and/or major blood vessels. This was evident in case 2 where no major structures were injured and the tube was successfully revised intra-operatively. Risk of intra-abdominal tube malposition can be seen if tubes are inserted below the “safety triangle” and poses risk to injure hollow and solid abdominal organs [10]. Other potential causes of intra-abdominal chest tube malposition include late pregnancy, intra-abdominal tumors, ascites, obesity or even full expiration [12]. In case 1 the tube perforated the left hemidiaphragm but luckily did not injure any peritoneal organs hence was managed conservatively after removing the chest tube.

There are numerous ways to prevent complications as elicited by Kerger et al. Trochar can be avoided, smaller-bore tubes can be used by Seldinger-technique and with the use of a dilator. The authors continue to add the use to blunt-dissection with digital palpation of the pleura can be sought when using larger bore tubes, however in general smaller tubes should be preferred when possible [13]. A thoracoscope can also be used if the setting allows however in a resource-limited setting like ours this was not feasible. Clinicians should also aim to insert the chest tubes through the “safety triangle” in order to avoid injuries to the breast tissue, internal mammary artery and external thoracic muscles [13].

4. Conclusion

Tube thoracostomy is one of the commonest life-saving invasive procedure, however, poses significant liability. Proper placement and evaluation is of utmost important. This series highlights the potential complications and create awareness for preventive strategies are fundamental for satisfactory patient outcomes.

Consent

Written informed consent was obtained from the patients and their respective caretakers for the publication of this case series and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

Ethical Approval was provided by the department of General surgery and hospital board on 01/03/2023, Ref: KCMC/D.GS/A.25/004.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contribution

Jay Lodhia – Conceptualization, writing and editing of the script

Mujaheed Suleman – Writing of the script

Samwel Chugulu – Review medical records

Kondo Chilonga – Editing of script

David Msuya – Clinical supervisor and editing of script

Guarantor

Jay Lodhia.

Research registration number

N/A.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Declaration of competing interest

The authors declare they have no competing interests.