Complications of chest tubes: a focused clinical synopsis.

REVIEW URRENT C OPINION

Complications of chest tubes: a focused clinical synopsis Melissa Mao a, Ronson Hughes b, Thomas J. Papadimos c Stanislaw P. Stawicki a,d

Purpose of review Chest tube placement, or tube thoracostomy, is an invasive procedure designed to evacuate air and/or fluid from the thorax, whether emergent or elective. In the placement of these devices particular attention and effort must be made to understand safe and reliable anatomic techniques and device maintenance so as to avoid serious injury to the patient. This review focuses on complications of chest tube placement, with the emphasis on patient safety and error prevention. Recent findings There is a paucity of high-quality recent literature on tube thoracostomy complications. With the advent of value-driven healthcare, increasing emphasis is being placed on appropriate procedural indications, procedural safety, and patient satisfaction. Good clinical outcomes are critical to achieve and maintain in this context. Summary Given the high volume of tube thoracostomies globally, greater awareness of potential complications and preventive strategies is needed. The authors attempt to bridge this important gap. Keywords chest tubes, complications, critical illness, maintenance, pulmonary, surgery

INTRODUCTION Tube thoracostomies are commonly performed invasive procedures, designed to evacuate air and/ or fluid from the thorax, whether emergent or elective, life-saving or palliative [1 ]. The restoration of intrathoracic pressure homeostasis and maintenance of intrathoracic volume available for lung expansion are key benefits of tube thoracostomy utilization [2]. The procedure is performed by thoracic surgeons, emergency physicians, intensivits, interventional radiologist, pulmonologist, and nonphysician advanced practitioners [3–6]. The concept of tube thoracostomy dates back to approximately 460 B.C. when Hippocrates described the treatment of empyema by incision, drainage, and insertion of hollow metal tube drains [7,8]. Chest tube insertion is performed in trauma patients with tension pneumothorax [9], routine postoperative care following thoracoscopy or thoracotomy [10], or for comfort in a patient with a malignant pleural effusion [11]. With such broad indications and wide array of providers placing chest tubes, it is imperative to be mindful of the many complications inherent to the procedure. The following concise

synopsis provides insights and cautions to practitioners who utilize this intervention.

INDICATIONS AND CONTRAINDICATIONS

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Among most common indications for tube thoracostomies are pneumothorax, traumatic injury (blunt/ penetrating), chylothorax, hemothorax (iatrogenic and traumatic), symptomatic pleural effusion, and routine postoperative thoracic management protocols [1 ]. Less common indications include bronchopleural fistula, chemical pleurodesis, and drainage of complex effusion or empyema [12]. &

a Department of Surgery, bLevel 1 Resource Trauma Center, St Luke’s University Health Network, Bethlehem, Pennsylvania, cDepartment of Anesthesiology, The Ohio State University College of Medicine, Columbus, Ohio and dDepartment of Research & Innovation, St Luke’s University Health Network, Bethlehem, Pennsylvania, USA

Correspondence to Stanislaw P. Stawicki MD FACS, Department of Research & Innovation, St Luke’s University Health Network, NW2 Administration, 801 Ostrum Street, Bethlehem, PA 18015, USA. Tel: +1 484 526 4426; e-mail: [email protected] Curr Opin Pulm Med 2015, 21:376–386 DOI:10.1097/MCP.0000000000000169 Volume 21 Number 4 July 2015

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Complications of chest tubes: a focused clinical synopsis Mao et al.

overview of chest tube-related complications is provided in Table 1. Although there are no absolute contraindications to tube thoracostomy placement, sound judgment is needed to assess the risk–benefit ratio for patients who are immunocompromised or have a coagulopathy [3]. In general, complications can be broadly grouped into those related to placement, maintenance, or discontinuation [3]. In order to standardize the subsequent discussion, ‘early’ complications are said to occur during the first 24–48 h,

KEY POINTS Chest tubes are among the most commonly performed invasive procedures. Due to their invasive nature, chest tubes can cause a number of potentially severe complications. Procedural safety and proficiency should be emphasized when credentialing providers to perform tube thoracostomy procedures. In the era of value-based healthcare delivery, the awareness of complications and ways to prevent morbidity translates into enhanced patient experience and customer satisfaction.

Table 1. Overview of chest tube complications Insertion-related complications Bronchopleural fistula

In the setting of trauma, most tube thoracostomies are performed for pneumothorax (54%) and hemothorax (20%), with approximately 90% of placements being done for blunt chest injuries [13]. In nontrauma setting, recurrent or symptomatic pleural effusion(s), thoracic or cardiac surgery, malignant pleural effusions, empyema, and chylothorax are among the more common indications. Of interest, tube thoracostomies may not be universally indicated in the elective pediatric population following thoracoscopy procedures, with one large series reporting only one out of 333 patients (0.3%) without chest drains requiring active intervention postoperatively [14]. Although chest tubes can be placed ‘blindly’, this approach should be avoided in those with a history of transplantation, intrathoracic scarring, and/or pleurodesis [1 ]. These patients may need pre-emptive imaging studies. Also, the specter of bronchopleural fistula should suggest caution in regard to tube thoracostomy placement in those with pulmonary blebs [15,16], as should the presence of coagulopathy (unless the situation presents an unequivocal emergency) [1 ]. &

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Cardiac/great vessel injury Contralateral pneumothorax Diaphragm injury Hemothorax Inadequately secured chest tube Injury to abdominal organs (related to mis-placement, concurrent diaphragm injury) Injury to intrathoracic and mediastinal organs/nerves Incorrect insertion distance (insufficient or excessive) Malposition of the chest tube Pulmonary bleb rupture Subcutaneous placement Vascular injury Infectious complications Empyema Necrotizing chest wall infection Placement site infection Postremoval chest tube site infection Mechanical complications Erosion into vascular structures Nerve/organ compression Tube dislodgement Tube erosion into intrathoracic structures Tube kinking

OVERVIEW OF CHEST TUBE COMPLICATIONS

Tube occlusion

The average complication rate of tube thoracostomy placement is five to 10% [1 ,13]. Individually, insertion-related complications are rare, and major complications tend to be equally uncommon [13]. Thus, the above rate reflects a variety of different complications occurring at various times during and following the index procedure. Among complications, frequently reported in large series are malposition of the tube [17], other technical complications (1%) [18], empyema (1–2%) [13], and bronchopleural fistula (rare) [1 ]. However, all vessels, organs, and nerves in the thorax are at risk for some sort of procedure-related misadventure. An &

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Miscellaneous complications Arteriovenous fistula Compression of the heart, with hemodynamic symptoms Horner’s syndrome Pleurocutaneous fistula Pulmonary infarction Recurrent pneumothorax Re-expansion pulmonary edema Retained catheter fragment Subcutaneous emphysema Thoracic duct injury Wound problem/infection

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Diseases of the pleura

whereas ‘late’ complications occur beyond this initial time period [19]. Cumulative rates of ‘early’ and ‘late’ complications are 3–5% and 8–10%, respectively [1 ]. Potential complications include injury to the heart, injury to the lungs, injury of the thoracic vessels, misplacement of tubes into soft tissue, or subdiaphragmatic placement with injury to spleen, liver, stomach, or bowel [20 ,21–23]. For the sake of organizational simplicity, the subsequent discussion will focus on each specific complication being listed and discussed independently. Prompt diagnosis of malposition can prevent complications resulting from injuries to structures in proximity to the tube [17]. The complication risk may be mitigated by using a larger tube and diligently confirming pleural space placement, avoiding trocar-based tubes, and applying a high volume, low pressure system for suction [15]. Additionally, one of the most common complications after tube thoracostomy for trauma is empyema [18]. It is important to note that ultrasound guided thoracentesis by interventional radiology is associated with a lower incidence of complications when compared with that done without direct image guidance [17,24]. If the operator is inexperienced or the fluid collection appears atypical or loculated, a stable patient is best cared for by ultrasound (or other imaging) guided thoracentesis [24]. &

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PROCEDURAL CONSIDERATIONS Outside of life-threatening emergencies, informed consent is required to acknowledge the risk of complications related to this invasive procedure. Implementation of a preinsertion checklist should be mandated to prevent misidentification or wrong side/site placement [1 ]. To ensure procedural safety, universal precautions must be followed. Careful consideration of indication(s) for placement will determine the chest tube’s length and internal diameter. As effluent flow rates decrease and/or viscosity of the drainage increases, the risk of tube thoracostomy blockage increases. To avoid tube occlusion, consideration should be given to the internal diameter of the device. A note must be made if there is no effluent and only air is to be evacuated. In the case of air drainage only, a smaller tube diameter, a ‘pigtail’ or a ‘dart’ catheter may be used [1 ,25]. Modern thoracostomies are made of synthetic materials, providing a flexible and translucent conduit for thoracic drainage [3]. An important, uniformly standardized identification marker, the ‘sentinel hole’ (Fig. 1), corresponds to a radiographic indicator that represents the distance between the inner rib shadows and the outer-most fenestration &

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FIGURE 1. Demonstration of the ‘sentinel hole’ or the most peripherally located intrathoracic opening in the chest tube (circle). By convention, the ‘sentinel hole’ is marked by a ‘gap’ within the radiopaque marker that continues along the length of the entire tube. This figure also demonstrates a case of a significant persistent pneumothorax (two-sided arrow) and subcutaneous air (star) despite an indwelling chest tube. A second chest tube was placed and the pneumothorax/subcutaneous air have subsequently resolved.

on the tube. During the initial placement procedure, the tube must be advanced until this marker is sufficiently intrathoracic, although it is important that the tube is not advanced too far so as to become kinked or forcibly leaning against intrathoracic or mediastinal structures [1 ]. Chest tubes are placed either by: percutaneous methods using a needle-introduced guide wire, an introducer sheath, and serial tract dilations; by blunt dissection; or using the trocar puncture technique. The percutaneous and the blunt dissection methods provide better control of placement and are the favored approaches when placing the tube directly. Alternatively, the trocar can be used for a quick and direct placement, with the tube thoracostomy fitted on top of a rigid and pointed internal metal obturator. Subsequently, the tube itself is advanced and the trocar gradually withdrawn. This method carries a greater risk of lung or other iatrogenic injury [3]. Detailing the procedural steps for all three types of tube placement techniques is beyond the scope of this focused review. &

COMPLICATIONS OF TUBE PLACEMENT Insertion-related complications include esophageal perforation, aortic impingement, laceration of vasculature, injury of organs above/below the Volume 21 Number 4 July 2015



diaphragm, diaphragmatic perforation or paralysis, and subcutaneous placement [1 ,5]. Additionally, positional complications may arise during the tube insertion procedure. Malposition of the tube may cause Horner’s syndrome, arteriovenous fistula formation, re-expansion pulmonary edema, contralateral pneumothorax or cardiogenic shock from compression of the right ventricle [1 ,19].

PHRENIC NERVE PALSY

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LUNG INJURY The most common organ injured during tube thoracostomy placement is the lung. Pulmonary lacerations are more common in patients with parenchymal consolidations, pleural adhesions, and/or poor lung compliance [1 ]. Bronchopleural fistulas (BPF) are pathological connections between the bronchial tree and the pleura. Although BPFs constitute an indication for chest tube placement, they may also result from tube thoracostomy placement and its use. Fortunately, the incidence of BPFs is very low [1 ]. &

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INTERCOSTAL ARTERY INJURY Intercostal vessels run along the inferior border of the rib. Blunt dissection over the superior rib border reduces, but does not eliminate, the potential for injury/bleeding. However, failure to do so can result in massive intrapleural hemorrhage [1 ]. In the elderly patient, intercostal vessels tend to become more tortuous [26], increasing the risk of injury. Bleeding may initially be masked by the tamponade effect provided by the chest tube itself. Intercostal vessel injury may predispose to fistula formation. Arteriovenous fistula formation and manifestation may be delayed up to several years after the index procedure, and is heralded by the appearance of a machine like murmur, pulsatile mass, and/or a palpable ‘thrill’ over the lesion [1 ]. &

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DIAPHRAGM INJURY Chest tube misplacement can result in diaphragm muscle dysfunction, laceration, or perforation. Intraabdominal tumors, significant ascites, obesity, late pregnancy, diaphagmatic dysfunction/paralysis, or diaphragmatic hernia may elevate the risk of diaphragm injury [1 ]. Diaphragm injury and abdominal chest tube misplacement have been reported following the use of a trocar type tube device placed at the level of the seventh left intercostal space in the mid-axillary line in the setting of hepatic cirrhosis, ascites, and large left pleural effusion [27]. In rare instances, similar occurrences may be associated with lung and gastric injuries [28]. &

Phrenic nerve palsy and acute diaphragmatic paralysis is an uncommon complication of tube thoracostomies placement, and is due to the compressive effect of a chest tube placed too close to the mediastinum [29]. It occurs most frequently in neonates [30]. Radiographic findings may include elevation of the hemidiaphragm and paravertebral location of the chest tube tip. It is recommended that the tip of the tube thoracostomy be situated at least 1–2 cm away from the spine in order to avoid this complication [29,30]. Patients with phrenic nerve palsy may be asymptomatic or may experience respiratory failure and inability to wean from the ventilator [29,31]. This complication is usually reversible with conservative management, with occasional cases requiring diaphragmatic plication [29–31].

CARDIAC AND GREAT VESSEL INJURY &

Heart laceration or compression is very rare [1 ]. It results from tube compression or penetration of the structure(s) in question during insertion. Clinically, a chest tube compressing the right ventricle or descending aorta may result in hemodynamic effects of varying degrees, whereas penetration of these structures will result in rapid blood loss evident on tube insertion accompanied by a temporally related hemodynamic catastrophe [1 ]. Also, extreme caution must be maintained with trocar tube thoracostomy placement in individuals with thoracic deformities. Fatal right atrial laceration during such placement has been reported in a patient with severe kyphoscoliosis and chest wall deformity [32]. Iatrogenic pulmonary artery injury necessitating repair under cardiopulmonary bypass [22], and even a subclavian artery erosion have also been described [21]. &

THORACIC DUCT INJURY Drainage of lymphatic fluid into the pleural space may result from tube thoracostomy-associated disruption of the thoracic duct [33,34]. The sine qua non for this very rare injury is the appearance of milky fluid drainage, which is due to the high lipid content of lymph. Confirmation is achieved by pleural fluid analysis that demonstrates triglyceride levels more than 10 mmol/L. Lymphatic injury will cause a right sided chylothorax if the insult is below the fifth vertebra and a left chylothorax will result if injury is above this level [1 ]. &

ESOPHAGEAL INJURY Esophageal injury following tube thoracostomy placement is rare. Presence of enteric, salivary




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content, or yeast in the tube thoracostomy container should raise suspicion for this complication [1 ,35]. In cases of pre-existing esophageal perforations treated with chest tube drainage (i.e., Boerhaave’s syndrome), placement of the tube thoracostomy must be performed very cautiously to avoid further injury to the esophagus. A posteriorly placed tube thoracostomy may migrate into the lumen of the perforated esophagus [36 ]. Additionally, a tube thoracostomy may perforate the surgical repair site following esophageal surgery [37]. Treatment follows the same principles as that of esophageal perforations in general. &

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EXTRATHORACIC VISCERAL INJURY Improper tube thoracostomy insertion may result in unintended intra-abdominal insertion [1 ]. The incidence of this complication is difficult to ascertain as most of the information is based on case reports. During the placement, the ‘safe triangle’ utilizes landmarks to aid in proper chest tube placement. The borders of this triangle include the anterior edge of the latissimus dorsi muscle, the lateral edge of the pectoralis major muscle, and a horizontal line at the level of the nipple [38]. Despite awareness of landmarks, the emergent nature of the tube thoracostomy procedure and patients’ varying body habitus can result in suboptimal tube placement and associated visceral (and other) injuries.

SPLENIC INJURY Splenic injury associated with tube thoracostomy placement is rare. An isolated report described a tube thoracostomy found to be traversing the spleen [20 ]. In that case, fibrin sealant was inserted through the tube as it was removed one week later, with no further complications [20 ]. In another instance, a tube thoracostomy placed in the left upper abdominal quadrant resulted in superficial injuries to the splenic capsule, but did not cause sufficient injury to necessitate splenectomy or other intervention(s) [1 ]. If associated hemodynamic compromise is present, one should consider either percutaneous splenic embolization or surgical exploration with splenic repair or removal. Splenic injury following left upper abdominal chest tube misplacement is shown in Fig. 2. &&

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GASTRIC INJURY Gastric injury from chest tube placement is associated with subdiaphgragmatic insertion [27]. This complication can also occur as a result of anatomically ‘proper’ tube thoracostomy placement in the presence of an unrecognized intrathoracic gastric herniation, typically with a concurrent diaphragmatic injury [39,40]. Surgical repair of gastric and associated diaphragm injuries is mandated.

HEPATIC INJURY Little information has been published on this rare complication of tube thoracostomy placement. In one case, the chest tube was removed without incident and without further intervention [41 ]. In other reports, hepatic embolization of bleeding was required after tube removal [42,43 ]. Hemodynamic instability in the presence of recent right-sided tube thoracostomy placement should raise suspicion that liver injury may have occurred. &&

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BOWEL INJURY Intra-abdominal tube thoracostomy insertion resulting in bowel injury can occur [23,44 ]. Iatrogenic perforation of the bowel from a tube thoracostomy has been described secondary to an unrecognized diaphragm defect through which the bowel had herniated into the thorax [23]. In such instance, chest tube insertion for suspected pneumothorax resulted in unintended tube placement into the bowel [23]. This complication requires prompt recognition and immediate surgical intervention/correction. An example of a misplaced chest tube that resulted in a bowel injury is provided in Fig. 3. &&

HORNER’S SYNDROME Horner’s syndrome is a constellation of miosis, ptosis, anhidrosis, and enophthalmos caused by sympathetic trunk injury [1 ]. It occurs in less than 1% of cases of tube thoracostomy placement [45], with data limited to case reports [46 ]. Horner’s syndrome can occur when the chest tube is inserted high into the apex of the pleura, in which the sympathetic ganglion is located. Mechanisms of injury include direct compression by the tube thoracostomy on the sympathetic ganglion, local inflammation, hematoma, fibrosis, or stretching of nerve fibers [47,48]. Horner’s syndrome related to tube thoracostomy placement may be more accurately confirmed with computed tomography (CT) scan than with chest radiography [49]. Recovery rates vary but more than half of cases exhibit full recovery [46 ,48]. Prompt recognition of the syndrome allows for appropriate repositioning of the tube thoracostomy in an attempt to prevent any permanent repercussions. &

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FIGURE 2. An example of a chest tube misplaced into the left upper abdominal quadrant, resulting in splenic injury. The patient subsequently underwent a laparotomy for the removal of the chest tube and splenectomy.

SUBCUTANEOUSTUBE PLACEMENT If tube thoracostomy placement does not result in passage of the tube into the pleural space, it will not function and most likely will be found in the subcutaneous tissues [1 ,4]. Risk factors for this complication include obesity, chest wall hematoma, multiple fractured ribs, and careless insertion. Bleeding may occur secondary to injury of the pectoralis muscle or of breast tissue in women [1 ]. An example &

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of a subcutaneously misplaced tube thoracostomy is provided in Fig. 4.

UNILATERAL RE-EXPANSION PULMONARY EDEMA Re-expansion pulmonary edema (RPE) following chest tube insertion is a serious and possibly lifethreatening condition. RPE typically has a rapid onset and mortality as high as 20% [50 ,51]. Patients may be asymptomatic or may exhibit dyspnea, tachypnea, tachycardia, productive cough, and cardiorespiratory collapse [51,52]. RPE occurs when there is rapid lung expansion after a period of acute or chronic lung collapse [51,52]. Risk factors identified with the development of RPE include concurrent presence of a pleural effusion [50 ], younger patient age, and greater initial lung collapse [52,53]. RPE has been reported after injury to a giant bulla, removal of a giant mediastinal tumor, decortication, sympathectomy for hyperhidrosis, and on occasion it can occur bilaterally or contralaterally, although it usually occurs ipsilaterally [54,55]. Treatment is supportive as the condition is often self-limiting, resolving within a week [50 ,51,52]. RPE has also been described after large volume thoracentesis, which will not be discussed in this review. &

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COMPLICATIONS DURING CHEST TUBE MAINTENANCE FIGURE 3. An example of a left upper abdominal chest tube that resulted in a colonic injury/perforation. The patient was taken to the operating room immediately after it was recognized that large bowel gas and feculent material was being evacuated into the pleural drain collection system.

Empyema Posttraumatic empyema has an incidence of two to 25% [56] and carries a mortality rate of 4% [57 ]. The rate of posttraumatic empyema is generally elevated in patients with retained hemothorax [58 ]. Other


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FIGURE 4. Computed tomographic scan demonstrating a subcutaneously placed chest tube (stars). The tube was removed and replaced by a properly positioned intrathoracic tube.

risk factors include prolonged tube thoracostomy duration, length of ICU stay, concomitant lung contusion, and need for laparotomy [56]. Treatment of posttraumatic empyema consists of a combination of intravenous antibiotics and surgical intervention (e.g., thoracotomy) [57 ]. High index of suspicion is of paramount importance. &

Pulmonary infarction Lung entrapment with focal infarction is rare [61]. It occurs when excessive suctioning is applied to the pleura resulting in aspiration of a segment of lung into the chest tube lumen. This complication can be avoided by using a low pressure, high-volume suction system. Pulmonary infarction may also lead to delayed lung perforation [1 ]. &

Necrotizing fasciitis Necrotizing fasciitis associated with tube thoracostomies is a rare entity [1 ,59,60]. Subcutaneous emphysema is one of its hallmarks. However, subcutaneous emphysema is sometimes an expected clinical finding with tube thoracostomies, and thus, may delay the diagnosis. Recognition of necrotizing fasciitis is critical due to its rapidly progressive and life-threatening nature, mandating urgent surgery, and broad spectrum antibiotics [1 ,59,60]. &

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Subcutaneous emphysema Subcutaneous emphysema can occur with tube thoracostomies. It usually involves the chest wall, neck, and face, but may spread further with large air leaks. Risk factors include poor tube placement, tube blockage, or migration of the ‘sentinel hole’ out of the pleural space [62]. If persistent, it may be treated with tube thoracostomy replacement, infraclavicular incisions down to the level of the pectoralis fascia, and placement of subcutaneous drains Volume 21 Number 4 July 2015


Complications of chest tubes: a focused clinical synopsis Mao et al. &

[62,63 ]. However, most occurrences are of minor consequence and require supportive treatment only.

percent of cases [66,67]. Factors contributing to the development of recurrent pneumothorax after removing a tube thoracostomy include severity of thoracic injury [68 ] and thinner chest walls [69 ]. Timing of tube thoracostomy removal in regards to inspiration or expiration is debatable, but there can still be air entry into the pleural space upon removal with either approach [discontinuation at endinspiration (8%) and end-expiration (6%)] [66]. An example of post-chest tube removal pneumothorax is shown in Fig. 5. For very small residual pneumothoraces in nonintubated patients, supplementation with high-flow oxygen may provide sufficient ‘nitrogen washout’ effect to facilitate complete resolution of the pneumothorax. Removing tube thoracostomies on ‘water seal’ versus suction is also controversial. In trauma patients, there is not a significant difference in the rate of recurrent pneumothorax after tube removal while on suction or ‘water seal’. One study found that trial of ‘water seal’ was associated with increased hospital length of stay and greater number of chest radiographs [70]. Another study demonstrated that more tube thoracostomy reinsertions were required when tubes were removed while on suction [67]. Clamping of tube thoracostomies prior to removal is another method employed to assess for pneumothorax resolution. A prospective randomized study demonstrated similar rates of tube thoracostomy reinsertion in the clamped (6.7%) and unclamped (4.6%) groups [67]. Approximately 10% of patients required unclamping due to &&

Arteriovenous fistula There have been several reports describing chest wall arteriovenous fistula (AVF) formation as a direct result of chest tube insertion [59,64]. Damage to intercostal vessels may lead to the formation of chest wall AVF’s between an intercostal artery and adjacent vein(s). Clinical manifestations include a palpable thrill, pulsatile mass, and/or audible bruit [59].

Chest tube dislodgement or disconnection Thoracostomy tubes are secured in place with one or more sutures. However, dislodgement or disconnection may occur along any point of the drainage system [1 ]. If this occurs, the initial indication for tube thoracostomy insertion may recur (i.e., pneumothorax, hemothorax, or pleural effusion). Patients may experience discomfort from the tube thoracostomy, and patient movement may cause excessive tube motion. Critically ill patients undergo frequent position changes by nursing staff that may also cause tube thoracostomies to shift [65]. It is important to identify the depth of the tube thoracostomy upon insertion to help verify displacement. Once dislodged, even partially, the tube thoracostomy needs to be removed and replaced due to infection risk associated with reinsertion of the externalized portion of the tube. &

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Complications following tube discontinuation A tube thoracostomy must be removed properly to avoid further complications. With all supplies readily available, dressings are carefully removed and the anchoring suture is cut. The tube thoracostomy is swiftly removed with one hand whereas the other hand is used to cover the incision with an occlusive dressing to prevent exposure of the tube thoracostomy site to the atmosphere (and thus, reentry of air into the chest) [1 ]. A ‘U-stitch’ may be placed around the tube thoracostomy during insertion and left untied and secured to the tube. This suture can then be tied down as the tube thoracostomy is removed to close the incision. It is often useful to have an assistant when removing chest tubes. &

Recurrence of pneumothorax Recurrent pneumothorax following tube thoracostomy removal is reported in around four to eight

FIGURE 5. An example of a post-chest tube removal pneumothorax (arrow); The patient required the placement of an image-guided pigtail catheter in order to effectively treat this residual pneumothorax.




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radiographic evidence of recurrent pneumothorax or development of symptoms. Clamping tube thoracostomies may help identify occult air leaks and prevent premature removal, but does not decrease reinsertion rates [71]. Many institutions employ algorithms for chest tube removal; however, it is up to the clinician which method is preferred and a consistent approach may be more important than the actual technique being used.

Pleurocutaneous fistula

cavity, there is evidence to suggest that thoracoscopy should be the first-line approach to this problem, followed by thoracotomy only if necessary [82].

Miscellaneous topics: pregnancy and spontaneous pneumothorax Although discouraged by some, tube thoracostomy placement during pregnancy is occasionally required, and can be performed safely provided that certain safety steps and pregnancy-specific anatomic considerations are followed [83,84 ,85 ,86]. In this population primary spontaneous pneumothorax (PSP) can present a problem, and although it rarely occurs, its consequences can be severe because of the effects of hypoxia on both the mother and the fetus. There have been several cases of spontaneous pneumothoraces reported in the pregnant population [83,86]. Of importance is the fact that the recurrence rate of PSP after the initial episode in the general population is 30% [87], but the risk of recurrence in parturients during labor may be as high as 44% [88]. There are two reports of women delivering infants with a tube thoracostomy in place [89,90]. Both of these women had recalcitrant conditions and needed surgery before delivery, with the infants subsequently doing well [86]. Macduff et al. [91] indicated that there is evidence to support simple observation and aspiration as effective during pregnancy, with the recommendation of elective assisted delivery and regional anesthesia at term (or close to term). There was low-level evidence that video-assisted thoracoscopic surgery should be done after delivery [91]. &&

A pleurocutaneous (or bronchocutaneous) fistula is an abnormal communication between the pleural space and subcutaneous tissue. It is very rare, with only a few case reports describing this as a direct result of a chest tube [72,73]. It is believed to be due to direct perforation of the lung, with the tube thoracostomy serving to create a fistulous tract to the skin [72]. Diagnosis may be confirmed with physical exam findings revealing a high-pitched squeak or rush of air from the tube thoracostomy site, and radiographic findings on plain films, CT scan, or ultrasound [72,73]. Surgical placement of fibrin glue to seal the fistula may be required [72], but it can also heal spontaneously [73].

Retained catheter or fragment The occurrence of retained tube thoracostomy or its fragment(s) has been described in the past [74–77]. Such events are extremely rare (Fig. 6), usually attributable to a number of interrelated team and systemic factors, and carry various medical and medicolegal consequences [78 ,79–81]. On the basis of clinical experience describing the management of other retained surgical items from the thoracic &

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CONCLUSION Chest tubes are valuable clinical tools and are utilized by practitioners from diverse specialties. Given the invasive nature of tube thoracostomy placement, clinicians must remain cognizant of the many complications potentially associated with this procedure. Moreover, practitioners should be aware of general guidelines for appropriate tube thoracostomy maintenance, as well as monitoring of patients for potentially preventable complications of the indwelling devices. The authors hope that with this knowledge, patient morbidity may be avoided or recognized and treated promptly, and that the corresponding care delivery can be ultimately enhanced. FIGURE 6. An example of unintentionally retained chest drain fragment (star) in the right hilar region. The patient subsequently underwent thoracoscopic removal of the fragment. 384


Acknowledgements Ethics statement: This research is performed in accordance to established academic ethics guidelines. Volume 21 Number 4 July 2015



Financial support and sponsorship None. Conflicts of interest None.

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Volume 21 Number 4 July 2015


Self-retaining chest drainage tubes.

Complications of malpositioned Jones tubes.

Specimen collection from chest tubes: A novel method.

Thoracostomy tubes: A comprehensive review of complications and related topics.

[Medical conditions of the leg: a clinical synopsis].

A Synopsis of Clinical Pharmacokinetic Alterations in Advanced CKD.

Neonatal chest and abdominal radiograph: identification of tubes and lines.

[Chest tubes in ICU: another "crunch" between France and England?].

Low incidence of complications with Freka PEG tubes.

Complications of Feeding Jejunostomy Tubes in Patients with Gastroesophageal Cancer.

Cholera: synopsis of clinical aspects and principles of treatment.

A synopsis of resampling techniques.

Cytochrome c oxidase: a synopsis.

A letter in response to "Thoracostomy tubes: A comprehensive review of complications and related topics".

Cardiophobia: a paradigmatic behavioural model of heart-focused anxiety and non-anginal chest pain.

A synopsis of the synopses, 2013-2014.

The New Theory of Heredity: A Synopsis.

Fibrocytes in pulmonary fibrosis: a brief synopsis.

Synopsis of Phyllosticta in China.

Motion-activated prevention of clogging and maintenance of patency of indwelling chest tubes.

Iatrogenic complications of chest tube placement in demented patients.

Active Clearance of Chest Tubes Reduces Re-Exploration for Bleeding After Ventricular Assist Device Implantation.

[The intrapulmonary pseudo-malposition of chest tubes in the computed tomogram (CT)].

Malposition of Subclavian Venous Catheter Leading to Chest Complications.