Chapter 38 ■ Thoracostomy 267

Fig. 38.17. Posterior view of thoracic organs. Traumatic

hemorrhage of the left upper lobe was due to perforation

by a thoracostomy tube.

A B

Fig. 38.18. Postmortem examination of an infant with bilateral pneumothorax, pneumomediastinum,

and pneumoperitoneum secondary to pulmonary air leaks. Attempted needle aspirations, as shown by

multiple skin puncture sites of the pneumomediastinum and pneumothorax (A), resulted in needle punctures of the liver (arrows, B) with peritoneal hemorrhage.

268 Section VII ■ Tube Replacement

Fig. 38.19. Scar from thoracostomy insertion, emphasizing the

importance of avoiding the breast area. Massaging the healed

wound with cocoa butter helps break down adhesions that lead to

dimpling at the scar.

Fig. 38.20. The thoracostomy tube is completely outside the

pleural space on this slightly oblique chest film. Note that the long

feeding tube is not in an appropriate position for transpyloric feeding. Indwelling tubes may dislodge when other emergency procedures are performed.

Fig. 38.21. The side holes of both thoracostomy tubes are outside the pleural space on this radiograph.

Fig. 38.22. The tip of the thoracostomy tube has been advanced

too far medially and is kinked against the mediastinum. Withdrawing

the tube 1 or 2 cm would improve drainage at the medial thorax.

Note the endotracheal tube tip in the right mainstem bronchus.

Chapter 38 ■ Thoracostomy 269

5. Misplacement of tube

a. Tube outside pleural cavity in subcutaneous placement (Fig. 38.20)

b. Side hole outside pleural space (Fig. 38.21)

c. Tip across anterior mediastinum (Fig. 38.22)

6. Equipment malfunction

a. Blockage of tube by proteinaceous or hemorrhagic

material

b. Leak in evacuation system, usually at connection sites

c. Inappropriate suction pressures (32) (Fig. 38.11)

(1) Excessive pressure

(a) Aggravation of leak across bronchopleural

fistula

(b) Interference with gas exchange

(c) Suction of lung parenchyma against holes

of tube

(2) Inadequate pressure with reaccumulation

7. Infection

a. Cellulitis

b. Inoculation of pleura with skin organisms, including Candida (33)

8. Subcutaneous emphysema secondary to leak of tension

pneumothorax through pleural opening

9. Aortic obstruction with posterior tube (34)

10. Loss of contents of pleural fluid

a. Water, electrolytes, and protein (effusion)

b. Lymphocytes and chylomicrons (chylothorax)

Emergency Evacuation of Air Leaks

Life-threatening air accumulations require emergency

evacuation. This provides temporary relief to the patient

while preparing for thoracostomy tube placement. The following techniques using modified equipment are less traumatic than using straight needles or scalp vein sets. We suggest using an anterior approach for emergency evacuation

because position will not interfere with the preparation of

the lateral chest site for an indwelling chest tube.

Tubes used for emergency evacuation require suction

pressures as high as 30 to 60 cm H2O to overcome the resistance of their small diameters (35). This requirement and

their tendency to occlude make these cannulas unreliable

for continuous drainage of a significant air leak.

A. Indications

Temporary evacuation of life-threatening air accumulations

while preparing for permanent tube placement

B. Contraindications

1. When patient’s vital signs are stable enough to allow

placement of permanent thoracostomy tube without

prior emergency evacuation

2. When air collection is likely to resolve spontaneously

without patient compromise (nontension pneumothorax)

A. Equipment

All sterile

1. Gloves

2. Antiseptic solution

3. 18- to 20-gauge angiocatheter (36)

4. IV extension tubing

5. Three-way stopcock

6. 10- and 20-mL syringes

B. Technique

1. Prepare skin of appropriate hemithorax with antiseptic.

2. Connect a three-way stopcock to an IV extension tubing. Connect syringe to three-way stopcock.

3. Insert angiocatheter at point that is

a. At a 45-degree angle to skin, directed cephalad

b. In second, fourth, or fifth intercostal space, just

over top of rib, well above or below the areola of the

breast

c. In midclavicular line (Fig. 38.23A)

4. As angiocatheter enters pleural space, decrease angle to

15 degrees with the chest wall and slide cannula in

while removing stylet (Fig. 38.23A).

5. Attach IV extension tubing to angiocatheter, open stopcock, and evacuate air with syringe (Fig. 38.23B).

6. Continue evacuation as patient’s condition warrants,

while preparing for permanent tube placement.

7. Cover insertion site with petroleum gauze and small

dressing after procedure.

B A

Fig. 38.23. Emergency evacuation with a vascular cannula. Puncture the skin and enter the pleura at a

45-degree angle, immediately above a rib.