gilbert

1. Chest Tubes: Indications, Placement, Management,
and Complications
Timothy B. Gilbert, MD,* Brian J. McGrath, MD,t and Mark Soberman, MD:j:
Gilbert TE, McGrath B], Soberman M. Chest tubes: indications,
placement, management, and complications.} Intensive Care
Med 1993;8:73-86.
Use oftube thoracostomy in intensive care units for evac-
uation ofair or fluid from the pleural space has become
commonplace. In addition to recognition ofpathological
states necessitating chest tube insertion, intensivists are
frequently involved in placement, maintenance, trouble-
shooting, and discontinuation ofchest tubes. Numerous
advances have permitted safe use of tube thoracostomy
for treatment of spontaneous or iatrogenic pneumo-
thoracies and hydrothoracies foUowing cardiothoracic
surgery or trauma, or for drainage of pus, bile, or chy-
lous effusions. We review current indications for chest
tube placement, insertion techniques, and available
equipment, including drainage systems. Guidelines for
maintenance and discontinuation are also discussed. As
with any surgical procedure, compUcations may arise.
Appropriate training and competence in usage may re-
duce the incidence of compUcations.
From the 'Cniversity of Maryland Medical Center, Division of
Cardiothoracic Anesthesiology, Department of Anesthesiology,
Baltimore, MD; the tDuke University Medical Center, Depart-
ment of Anesthesiology, Durham, NC;and *the Cleveland Clinic
Foundation, Department of Surgery, Cleveland, OH.
Received Mar 17, 1992, and in revised form Sept 2. Accepted for
publication Sept 4, 1992.
Address correspondence to Dr Gilbert, Department of Anesthe-
siology, University of Maryland at Baltimore, South Hospital, 11th
Floor, Wing C, 22 South Greene sr. Baltimore, MD 21201-1595.
Historical Development
Drainage of the pleural space by thoracostomy
originated with Hippocrates around the fourth cen-
tury B.c. Using rudimentary skills of incision and
cautery, he inserted a metal tube for the treatment
of empyema, noting ". . . if pure and white pus
flow from the wound, the patients recover; but if
mixed with blood, slimy and fetid, they die" [1J.
Despite its prognostic utility, his metal tube tech-
nique failed to enjoy widespread use until well into
the nineteenth century.
Anel (around 1700) adapted a large syringe at-
tached to many funnel-shaped cannulae for tempo-
rary aspiration of pneumothoracies in casualties of
war, whereas his contemporary Boerhaave applied
suction through a blunt-tipped flexible tube perfo-
rated laterally [2J. However, aspiration of pleural air
or fluid become commonplace only after the sim-
ple hypodermic syringe was developed [3]. Playfair
(1872) recognized the importance of maintaining a
fluid seal to prevent entrainment of air [4]. Shortly
thereafter, Hewitt (1876) described a completely
closed apparatus, the basic design of which allowed
both drainage and irrigation of the pleural space
[5]. A relative hiatus occurred until the influenza
pandemic of 1917 necessitated reintroduction of
tube thoracostomy for drainage of postpneumonic
empyemas, following the report of Major Graham
and the Empyema Commission [6]. Use in surgical
patients following thoracotomy was advocated by
Lilenthal (1922) [7], but its application during
trauma resuscitations did not become accepted
practice until World War II [8J and the Korean con-
flict [9].
Indications and Contraindications
for Placement
Currently accepted indications for chest tube place-
ment are listed in Table 1. Most applicable to the
field of critical care medicine are iatrogenic
pneumothoracies, traumatic hemothoracies, and
placement following cardiothoracic surgery. The
need for placement (and its urgency) often depend
Copyright © 1993 Blackwell Scientific Publications, Inc. 73

2. 74 Journal of Intensive Care Medicine Vol 8 No 2 March-April 1993
Table 1. Indications for Chest Tube Placement
Pneumothorax
Spontaneous
Iatrogenic
Tension
Ilemothorax
Traumatic
Spontaneous
Postoperative
Pleural effusion
Parapneumonic or empyema
Malignant
Sympathetic effusion
Esophageal perforation
Chylothorax
Postsurgical
Thoracotomv
Cardiac .
Bronchopleural fistula
Hypotension in patients with chest trauma
Lung abscess
Thoracostomy rewarming lavage
Contrast thoracograrns
Sclerotherapy
on the specific clinical situation, patient symptoms,
and degree of underlying lung pathology.
Spontaneous or iatrogenic pneumothoracies of
less than 25% volume (<4 cm apical collapse or < 1
em lateral collapse [10-12]) in asymptomatic or
minimally symptomatic patients without severe pul-
monary disease may be observed for increasing
size. Bedrest and restricted exertion are suggested
[13], especially if the separation of visceral and pari-
etal pleurae is so small that the underlying lung
may be damaged by chest tube insertion [14]. Con-
versely, patients with severe distress, expanding
pneumothoracies (confirmed on serial radio-
graphs), or severe lung disease who may not toler-
ate minimal loss of lung function should be consid-
ered for urgent chest tube placement. Some
authors advocate needle or intravenous (IV) cathe-
ter aspiration as an alternative [15-17].
Any pneumothorax under tension as evidenced
by cardiovascular depression or mediastinal shift
on chest radiograph should have immediate de-
compression by needle first, unless definitive tube
thoracostomy is readily available. Roughly 80% of
patients with spontaneous pneumothoracies
treated with tube thoracostomy will have straight-
forward recovery. Further management by open
pleural abrasion [18], pleurodesis [19], or pleurec-
tomy with wedge resection of the ruptured bleb
is indicated for pneumothoracies with large per-
sistent air leaks, pneumothoracies complicating
bullous disease, or recurrent pneumothoracies
[10-12].
Spontaneous pneumothorax occurring in pa-
tients with certain underlying systemic diseases
(e.g., Marfan syndrome, cystic fibrosis, malignan-
cies) should also be considered for open thoraco-
tomy to prevent recurrence [20]. Recurrent catame-
nial pneumothorax should be considered an
indication for diaphragmatic exploration [21].
Spontaneous pneumothorax occurring in patients
with acquired immunodeficiency syndrome (AIDS)
typically poor surgical candidates, may best be
treated by tube thoracostomy and closed pleurode-
sis [22]. Thoracoscopic pleurodesis and wedge re-
section have been performed; however, long-term
results are as yet unknown.
Traumatic pneumothoracies generally follow
similar guidelines as spontaneous pneumothora-
cies, although the need for repeat tube placement
for recurrence is increased [23]. The appearance of
a pneumothorax of any size during the use of posi-
tive pressure ventilation warrants tube thoracos-
tomy placement, because rapid expansion is possi-
ble [10,20,24,25]. Bilateral tube thoracostomies
have been used prophylactically in patients with
severe acute respiratory insufficiency requiring
positive pressure ventilation in excess of +40 cm
H20, but its efficacy has not yet been confirmed
[26].
Large, acute fluid accumulations (e.g., traumatic
hemothorax), which can occupy the entire
hemithorax, require immediate tube drainage, a
common therapeutic intervention during trauma
resuscitations [27-29]. Criteria for further manage-
ment by open thoracotomy is discussed elsewhere
[10,30-32]. Penetrating trauma, especially if com-
bat-related, will be more likely to require open
drainage and repair [33]. Spontaneous hemothorax
is infrequent; it is more common in patients with
coagulopathies, and should be treated if large, ex-
panding, or symptomatic. Chylous effusions may
eminate from injury to the thoracic duct [34]. Other
cavity fluids, such as bile [35] and urine [36], from
pleuroperitoneal communications have also been
drained using tube thoracostomies.
Pleural effusions, which usually evolve over days
or weeks, may undergo tube thoracostomy for both
diagnosis and symptomatic relief. Transudative ef-
fusions, especially when small and mobile, may be
observed for expansion. True empyemas and com-
plicated parapneumonic effusions (satisfyingLight's
criteria [37]) have historically been drained by tube
thoracostomy, usually following diagnostic thora-
centesis [38,39]. Some authors have suggested
thoracoscopy [40], minithoracotomy [40,41], repeti-
tive thoracentesis [42], or IV catheter drainage [43-
45] as alternatives. However, a recent retrospective
study compared treatment of complicated para-

3. pneumonic effusions with antibiotics with or with-
out drainage. Morbidity, mortality, and clearance
time were similar; resolution occurred in 81% (11
of 16 patients) treated with antibiotics alone [46].
Empyemas secondary to trauma, which may fail to
improve following initial tube thoracostomy, may
more likely need open decortication for resolution
[23,47,48]. Postoperative empyema" may act simi-
larly [49]. In patients with recurrent malignant effu-
sions, antineoplastic agents can be administered di- .~
reedy through thoracostomy tubes [50,51];
incidence of drug exposure throughout the pleural
space is high and reduces systemic exposure to
antitumor agents [52].
Closed pleurodesis with irritants such as talc, te-
tracycline, or silver nitrate for recurrent pneurno-
thoracies or hydrothoracies can be performed at
bedside [10,19,50,53,54], preferably with concur-
rent administration of local anesthetics to reduce
discomfort [55].
Only rarely has tube thoracostomy been used in
place of formal open drainage for lung abscesses
[38,56,57] and giant emphysematous bullae [58-60]
in patients believed to be high surgical risks. Equip-
ment and personnel for emergency placement of a
chest tube should be readily available whenever
any patient with giant bullae receives positive pres-
sure ventilation [61]. Posttuberculous broncho-
pleural fistulae can also be treated initially with
closed tube thoracostomy, although most ulti-
mately require open thoractorny window or decor-
tication (62).
Thoracostomy tubes have been used as access
devices for continuous warm saline pleural lavage
in severely hypothermic patients in both emer-
gency resuscitation [63,64] and operative manage-
ment [65), as well as for injection of contrast agents
for detection of diaphragmatic rupture in blunt
trauma patients [66]. Evulsion biopsy of the pleura
can be performed concomitant with insertion of
thoracostomy tubes if the blunt dissection tech-
nique is employed [67,68).
Although no absolute contralndtcations to chest
tube placement exist (other than patient refusal
[69)), physicians must use judgment in determining
the relative risks in patients with coagulopathies or
immunosuppression. Some authors suggest even
more aggressive management in immunosup-
pressed patients, including open thoracotomy for
most empyemas [49,70].
Methods of Insertion
Equipment. Components necessary for closed
thoracostomy tube placement include appropriate-
Gilbert et al: Chest Tubes 75
I
I
Fig 1. Typical presterilized equipment tray contains
supplies necessary for immediate tube thoracostomy
placement. Straight and angled chest tubes are also
shown, which are selected according to patient re-
quirements.
sized chest tubes, a drainage device with or without
a suction source, connecting hoses with connec-
tors, and a tray of insertion instruments (Fig 1).
Presterilized supplies (without chest tube or drain-
age system) available in out' institution are listed in
Table 2.
Modern chest tubes are constructed of translu-
cent, minimally thrombogenic, pliable polyvinyl
plastics and are nonpyogenic and disposable. They
must conform to applicable federal guidelines
(American National Standards Institute), and they
are implantation-tested and sterilized. Older rub-
ber tubes, which irritate the pleura and produce
adhesions, have occasionally been used to treat re-
current spontaneous pneuothoracies [71]. Available
in a variety of internal diameters OD), typical adult
Table 2. Suggested Sterile Thoracostomy Insertion
Supplies
Clamp: large Kelly, 2
Cups for scrub and anesthetic, 2
Drape with center hole, 1
Hemostats: straight and curved, 2 each
Local anesthetic
Needle holder, 1
Needles: no. 18, no. 22, and no. 25, 1 each
Scalpel blades: no. 11 and no. IS, 1 each
Scalpel handle, 1
Scissors: Mezenbaum, 1
Sponges: 4" x 4", 10
Suture, nonabsorbable: 1-0 or 0-0; cutting needle, 1
Syringes: 5 and 10 mL, 1 each
Towels, 4
Tray and coverings

4. 76 Journal of Intensive Care Medicine Vol 8 No 2 March-April 1993
sizes range from 5 to 12 mm (no. 16-38 French),
whereas 2- to 8-mm devices (no. 6-24 French) are
used primarily in pediatric patients. Straight tubes
for anterior, lateral or posterior placement are
available with or without internal trocars. Angu-
lated tubes are used predominantly for dependent
supradiaphragmatic positions without trocars. All
are typically imprinted with distance markers for
determining insertion. depth, and a radiopaque
stripe for radiological confirmation of proper
placement. The proximal end is slightly flared for
connection to the suction apparatus, and the distal
end is slightly tapered and fenestrated with multi-
ple drainage holes to prevent clogging. Modified
catheters, such as the tunnel tip thoracic catheter
with a severely tapered tip [72], and catheters in-
tended for suprapubic [73], bladder [9],or pericar-
dial drainage [74,75] may be useful for specific or
difficult placements. Combined catheter/flutter
valve systems for emergency use by prehospital
personnel have been developed [76,77], because
formal tube thoracostomy placement in the field is
rarely justified [78].
Resistance to air flow within a chest tube system
increases with decreasing diameter, increasing
length (including connecting hoses), and aspiration
of fluid-saturated air [79]. Pressure and flow rela-
tionships are generally not linear because of the
circuit's complex geometry, including bore irregu-
larities such as kinking, clotting, and distal hole oc-
clusion [80]. The ideal circuit would allow little re-
sistance to either air or fluid passage, neither leak
nor occlude easily, and provide a constant source
of negative pressure to the pleural space.
Timing and Location of Placement. The rela-
tive urgency for placement of a chest tube often
depends on the clinical scenario during which air
or fluid accumulates in the pleural space. Location
of the insertion site depends historically on the
contents being drained from the pleural cavity,
most often directed by routine chest radiography.
Obtaining an upright, anteroposterior (AP) chest
film after a period of erect posture may gravitate
mobile effusions to dependent areas or air to the
apicies, which may be difficult to visualize on rou-
tine supine films. Illustrations of tube placement
can be found in the literature [15,81-83].
Free pleural air has commonly been aspirated
from the wide, second intercostal space in the mid-
clavicular line, because air gravitates superiorly in
semiereet patients. More medial placement is pro-
hibited by the traversing internal mammary artery.
The fourth or fifth intercostal spaces in the midaxil-
lary line are often used to avoid obvious scarring.
In addition, the tube may also be easier to place,
better tolerated, and less restrictive for respiratory
care [40]. Use of the second intercostal space may
be preferred in infants, because an anterior loca-
tion within the pleural cavity is more readily
achieved with improved air evacuation [84]. This
location may be reserved as an auxiliary site in
adults to augment evacuation of residual air [81].
Lateral tubes placed for air retrieval are angled an-
teriorly and apically.A posterior approach has been
described for refractory apical air collections when
anterior and lateral adhesions prevent insertion
[85].
Hydrothoracies, whether blood, pus, or lymph,
are usually approached laterally through the fourth
or fifth intercostal space in the midaxillary line with
a larger bore tube (7-12 mm), depending on the
viscosity of fluid encountered and likelihood of
clotting. Placement of the chest tube posterobasally
in the dependent paravertebral gutters (in supine
patients) may facilitate drainage in certain situa-
tions.
Insertion Techniques. Three techniques for in-
sertion are available and are in general a matter of
personal preference, although ease of use and com-
plications may differ. The two direct techniques,
which require surgical incision, are (1) blunt dis-
section and (2) trocar puncture. Anewer technique
requires a minimal incision by placing the chest
tube indirectly with guidewires or introducers into
the pleural cavity. This percutaneous method has
found utility among physicians inexperienced in di-
rect methods [86,87].
Regardless of technique, the site selected must
be decontaminated with povidone iodine, chlor-
hexidine, or other surgical scrub, and draped ap-
propriately to maintain view of anatomical land-
marks. Innervated by ventral intercostal nerves, the
chest wall requires generous local anesthetic infil-
tration into the subcutaneous, periosteal, and pari-
etal pleural tissue layers to prevent untoward dis-
comfort. Anylocal anesthetic can be used; however,
bupivacine or etidocaine may provide prolonged
analgesia. Intravenous sedation with short acting
agents such as fentanyl citrate or midazolam hydro-
chloride should be considered in appropriate situa-
tions with proper monitoring. Supplemental oxy-
gen may be required in many situations.
For direct insertion techniques (Fig 2), the over-
lying skin is pulled superiorly to create a diagonal
insertion tract, which later will readily seal after
tube removal. A 2 em intercostal incision just supe-
rior and parallel to the caudad rib is made through
skin and subcutaneous tissues. A larger incision
may predispose the site to an air leak, whereas a
smaller incision may impede tube placement. Digi-

5. Gilbert et al: Chest Tubes 77
Fig 2. Technique for blunt dissection method of tube
thoracostomy placement. (A) Following intercostal
incision. a clamp bluntly dissects the anatomical layers
toward the pleural space; (8) the index finger palpates
the incision and confirms proper entrance into the '
pleural space ; and (C) the chest tube is guided by
attachment to a clamp into the pleural space, After
clamp removal, the tube is advanced into proper posi-
tion,
tal palpation through the incision confirms proper
direction between the ribs and toward the pleural
cavity,
Blunt dissection affords greater control in place-
ment of a pleural tube and is currently the more
common method used with direct techniques, A
large. curved [24.88]. or straight [89] clamp placed
in the prepared incision is used to bluntly spread
the pericostal layers. followed by repeated digital
confirmation of proper direction. Finger palpation
will also detect pleural puncture and assist removal
of any pleural-based adhesions. A clamp affixed to
the proximal end of the chest tube facilitates inser-
tion through the chest wall and into the pleural
space by supporting and directing the flexible tube.
The trocar puncture technique uses a chest tube
fitted with an internal sharp and rigid metal obtura-
tor, which readily penetrates the suprapleural tis-
sues. Using direct pressure in a twisting motion,
this trocar-tube is judiciously inserted until a char-
acteristic "pop" denotes pleural entrance. Afterthe
pleura is entered, the tube is fed over the trocar
into the pleural space. Unfortunately, such sharp
trocars are associated with greater incidence of
lung or other thoracic injuries [90-92]. Euphemisti-
cally dubbed an "intercostal dagger" [93], some au-
thors avoid the trocar technique to prevent injury
to underlying lung, intercostal vessels, and other
visceral organs [24,94,951· Safety may be improved
when small-caliber chest tubes are employed (e.g.,
3 mm tube with 18 gm trocar [96D.
Percutaneous methods, using a large-bore, nee-
dle-placed guidewire with an introducer sheath,
Confirmation of Proper Placement. Routine
chest radiography should follow any attempted
chest tube placement. Ideally, AP and lateral views
should be obtained, because certain ectopic loca-
tions may not be discerned on AP view alone (e.g.,
within interlobar fissures [96,102,103D.
In a retrospective study of 26 patients with thora-
costomy-drained empyemas, only 4.8% (l of 21) of
malpositioned tubes were identifiable on AP view
alone, whereas an additional lateral view recog-
nized 89% (8 of 9). Computer-assisted tomography
(CAT) scan identified all 21 incidences of rnalposi-
tion [104]. Displacement of a tube 's radiopaque
marker on serial radiographs may denote lobar col-
lapse [105). Ultrasonography, real-time fluoroscopy,
and CAT scans have also been used for chest tube
localization or placement. Image-guided catheter
placement for empyemas or loculated effusions
may improve the overall cure rate (106). Fluid locu-
combine the aspects of a small incision with the
safety of controlled serial dilation [97,98]. Devel-
oped for the treatment of pneurnothoracies using
small-bore tubes, minimal complications with im-
proved patient comfort have been reported [86,87].
Malignant effusions and infected bullae have been
treated similarly, although fibrin clot obstruction
and inadvertent dislodging of the catheter during
transport have occurred, suggesting a disadvantage
.--'. of the small-bore system [87]. Currently, large adult
tubes (i.e., up to 11 mm) can be placed with percu-
taneous techniques using serial dilators instead of
introducer sheaths [93].
After insertion by one of the above methods and
removal of placement devices (trocar or clamp),
the tube is further advanced in the direction dis-
cussed to a depth beneath the skin at least 2 to 3 em
greater than the most distal drainage hole. Release
of trapped air or fluid suggests entrance into the
pleural space. A slight twisting motion, using a fin-
ger beside or through the insertion site, may aid in
proper tube direction and placement. Two simple
or horizontal mattress sutures of generous depth
placed on either side of the insertion site should be
placed to properly anchor the tube. Several ad-
juncts for securing tubes' have been described
[99,100]. Sterile dressings, 'preferably with antibi-
otic Ointment, cover the site. Petroleum-coated
gauze as an occlusive seal is no longer recom-
mended because integument breakdown can occur
and predispose to wound infections [88]. All con-
nections should be supplemented with sturdy tape
or plastic banding to prevent disconnection. Safety
pins or rubber bands are suggested to attach the
connecting hoses to the patient's clothing or bed, to
prevent dislodgment [101].
c
B
A

6. 78 Journal of Intensive Care Medicine Vol 8 No 2 March-April 1993
From
Pleural-.-
Cavity
One-Bottle
System
From
Pleural----.
Cavity
Two-Bottle
System
From
Pleural-.-
Cavity
Three-Bottle
System
CollecUon Bailie
-.. To Suction
~ To Suction
~AlmOSPheriC Vent
....... ToSuction
Suction Control
Fig 3. One-, two-, and three-bottle
systems for drainage of the pleural
space are shown. Typical water seal
levels of 2 cm H20 and suction
control levels of 20 cm H20 are
demonstrated.
lations can be located and marked in the radiology
department, with subsequent tube placement by
qualified radiology or other personnel. Tube
tracks, skin holes, air-fluid levels, and pleural thick-
ening may remain visible radiologically for several
weeks following removal due to a local serositis
from the prosthetic tube [107,108]. These radio-
graphic densities may mimic more serious con-
ditions, such as bullous disease, atelectasis, or
recurrent pneumothorax [109]. The radiopaque
bullet-shaped tip of a chest tube has also been con-
fused with an actual bullet in a gunshot wound
victim [110].
Drainage Systems
Prior to insertion of a chest tube, an appropriate
drainage device should be prepared for immediate
attachment. Although currently available devices
vary Widelyin appearance, size, and complexity, all
devices consist of a combination of one or more of
the following: (1) water seal, (2) drainage trap, (3)
pressure control chamber, and (4) connecting
hoses. At a minimum, a drainage device requires a
water seal that prevents air entrainment into the
pleural cavity while air or fluid are being drained
externally. In the case of simple pneumothorax,
this may consist of a l-bottle water seal [111]vented
to atmospheric or lower pressure (Fig 3, top). Un-
fortunately, this simple device is not adequate for
fluid collections, because the intrapleural pressure
required to overcome the water seal increases as
fluid accumulates within the bottle, necessitating
frequent emptying. Addition of a trap to collect the
pleural effluent creates a 2-bottle system, with the
trap upstream from the water seal (Fig 3, middle),
thus obviating repeated water seal adjustments.
Most modern drainage devices consist of an addi-
tional third bottle (Fig 3, bottom) that acts as a
control chamber to maintain constant negative
pressure; the height of water within the bottle regu-
lates the suction applied to the pleural space. These
devices are typically capable of delivering up to
- 30 ern H20 suction pressure. Greater negative
pressures in excess of -60 cm H20 may be
achieved by filling this chamber with fluids of
higher density, such as mercury [112]. More elabo-
rate devices (4 or more bottles) exist for balanced
drainage and irrigation of the pleural space [113].
Commercially available devices compartmental-
ize the antiquated 3-bottle system into 1 disposable,
lightweight plastic, transportable apparatus, which
allows regulation of both water seal threshold and

7. Fig 4. Commercially available drainage systems com-
partmentalize water seal, suction control, and drainage
trap into a single, disposable, light-weight transportable
system.
vacuum pressure control (Fig 4). Some systems
(e.g., Pleurevac) retain the classic water column for
suction regulation, whereas others (e.g., Davol)
employ a valve to regulate the amount of suction
applied to the pleural space. Quantitation and sam-
pling of effluent should be readily obtainable from
a translucent chamber with a capacity of at least 1 L
(preferably 2L). Most devices must be maintained
on a level surface, and adequate safety suppons or
brackets should be attached to prevent tipping, loss
of water seal, or cross-mixing of chambers. Each
device differs in size, cost, drainage capacity, flow
characteristics, and maximum pressure achieved-
the last is limited primarily by the flow rate of the
suction source and the internal resistance of the
drainage unit [114].
Because reabsorption of air in the pleural space
proceeds at only roughly 1% of lung volume per
day [115], suction is generally applied through the
drainage system. In fact, negative suction pressure
should generally exceed any potential positive ex-
piratory pressure to prevent reaccumulation of air
in the pleural space. In most fluid collections, suc-
tion is normally required for its mobilization and
for maintenance of tube patency. A notable excep-
tion is malignant pleural effusion, which may be
2
eM
i
T
20
CM
r
Gilbert et al: Chest Tubes 79
best managed by initial drainage by water seal
alone. Suction may induce partial pleurodesis, thus
decreasing the efficacy of subsequent chemical
pleurodesis. Application of suction may increase
the incidence of bronchopleural fistula formation
or reexpansion pulmonary edema [10,12]. The
amount of suction applied to the pleural space
should be determined by medium to be drained,
size of the patient (i.e., adult vs pediatric), and
amount of air leak present, given the constraints of
any individual drainage apparatus [116]. More than
one chest tube may be siphoned into a drainage
unit through "y" connectors, although flow per
tube decreases,
Flutter valves-as exemplified by the Heimlich
[117], Vycon or Thomas [12] devices-are substi-
tutes for formal water seal, and consist of a small
one-way rubber valve attached directly to the distal
end of the chest tube. These devices are primarily
used for pneumothorax evacuation (especially in
the ambulatory population [11,12]) and to facilitate
patient transport. In selected patients with persis-
tent air leak with either a stable pneumothorax or
no pneumothorax, placement of a flutter valve may
avoid thoracotomy or discharge from the hospital
in cenain high-risk pauend (e.g., those with AIDS
or elderly debilitated patients). Effluent from these
devices can readily be collected via colostomy
[118,119] and urinary drainage bags [120].
Connecting tubing should be at lea'it 1.3 em in
diameter to accommodate high gas flows (up to 60
Llmin [116]) and no more than 200 em in length.
Resistance to flow is increased unacceptably in ex-
cessively long or narrow hoses [79]. Preferably, tub-
ing should be translucent enough to visualize clots
and sufficiently stretchable to allow "milking." Tub-
ing connectors, the narrowest component in the
drainage system, should be similarly clear, un-
breakable, and typically 6 to 12 mm in diameter.
They are the source of greatest resistance to air or
fluid flow and a common site of obstruction.
Maintenance
The functional status of each chest tube and drain-
age device needs to be assessed frequently to rec-
ognize and prevent complications. All components
from the insertion site to the drainage device (in-
cluding each individual chamber) should be in-
spected for leaks and improper function. Coordi-
nated motion of the water seal level and patient
respiration implies appropriate continuity with the
pleural space. However, when a persistently nega-
tive column in the water seal chamber is main-
tained with a well-expanded lung, effective pleuro-

8. 80 Journal of Intensive Care Medicine Vol 8 No 2 March-April 1993
desis is generally present. Periodic "milking" or
"stripping" of connecting hoses is almost univer-
sally advocated to maintain patency, despite a lack
of objective data to support the practice [121]. In
fact, pressures exceeding -400 em H20 have been
recorded at the junction of the chest tube and con-
necting hose during stripping [122]. If air alone is
being evacuated, stripping is unnecessary [123].
If continuous bubbling through the water seal
chamber' develops, intermittent clamping of the
connecting hoses commencing at the drainage de-
vice and continuing toward the patient will reveal
most sources of leakage. Connectors are notorious
sites of air entrainment. Aircan also leak adjacent to
the chest tube through an improperly sized inser-
tion channel, which is best repaired by additional
suturing. Persistent air leaks can suggest broncho-
pleural fistula. A large bronchopleural fistula may
prevent appropriate alveolar ventilation and carries
a high mortality [124J. High-frequency jet ventila-
tion techniques [125], independent lung ventilation
[126], intermittent inspiratory chest tube occlusion
(IICTO) [105,127,128], and chest tube pressuriza-
tion (CTP) [25] have been developed as effective
interventions for controlling severe broncho-
pleural fistulas.
Rough quantitation of air leak (Umin) can be
estimated on most commercial drainage systems by
observing bubble flow through gradient tubes in
the water seal chamber. Occlusion of the tube
should be suspected if no respiratory variation of
the water seal chamber is noted. Saline irrigation
should be attempted initially [40]. Sterile passage of
a suction or Fogarty embolectomy catheter can also
extract occlusive clot [129]. Eibrinolytic agents are
infrequently used to remove refractory occlusions
[130,131]. Blockage of the tube from within the
hemithorax may occur from closely opposed
pleura and lung tissue or from placement within
interlobar fissures (the major fissure is the more
likely site [101,103]). Polyvinyl tubes tend to be-
come more pliable at body temperature, resulting
in kinking subcutaneously or intrapleurally.
Ultimately, replacement of a nonfunctional chest
tube through a second site may be necessary if per-
sistent occlusion is not correctable. Prolonged
clamping of chest tubes during active pleural drain-
age, as during transportation or patient care, should
be avoided because rapid reaccumulation of air can
result in tension pneumothorax [9,10] or increase
risk of disconnection [132]. Likewise,clamping dur-
ing performance of cardiopulmonary resuscitation
(CPR) to prevent loss of intrathoracic pressure is
not recommended, because pneumothorax may
impede venous return and impair oxygenation
[133]. Variations in intrapleural pressure do not
seem to have a significant influence on CPR [134].
When suction is discontinued for placement on wa-
ter seal, the suction tubing should be removed
from the drainage device. Although most modern
systems have a valve to relieve excessive positive
pressure, suction tubing connected to the system
(without applied suction) does not allow for egress
of air via the usual route.
Pain management for thoracostomy patients, es-
pecially if accompanied by an incision for car-
diothoracic surgery, may be problematic. In addi-
tion to routine systemic or regional analgesia, local
anesthetic infiltration at the insertion Site, transcuta-
neous nerve stimulator (TENS) units, and intercos-
tal nerve blocks (including cryoablation) may be
useful adjuncts. Pleural anesthetics can be given di-
rectly through chest tubes [135], through a catheter
secured within chest tubes [136], or directly
through the chest wall with a percutaneously
placed [137,138] or a surgically placed [139,140]
epidural-type catheter. A posteriorly placed cathe-
ter with the patient supine yields greater absorp-
tion near proximal portions of the intercostal
nerves [135,141]. Evaluation of pain relief with
these techniques vary among studies [135,139,141-
143]. Adverse effects have been noted with intra-
pleural anesthetics, including inadequate relief
[140,143] and absorption of toxic doses of local an-
esthetic with systemic effects [143,144].
Discontinuation and Removal
Tube thoracostomy can be discontinued whenever
the presenting indication is resolved or the appa-
ratus becomes nonfunctional. For pneumothorax,
this generally implies near-complete resolution of
pleural air (less than 10% residual pneumothorax)
without detectable air leak in the water seal cham-
ber. For fluid, drainage rates of less than 50 mL
every 8 hours (150 rollday) are desired. Chest
tubes are commonly not removed until after posi-
tive pressure ventilation is discontinued, although
this practice is not universal [20]. Prior to removal,
some authors suggest a short period (12-24 hr) of
water seal without suction, followed by briefclamp-
ing of the connecting hose to ascertain if reaccumu-
lation of air or fluid has occurred [10]. Signs of
expansion or tension must be monitored if clamp-
ing is performed [11,101]. Removal of the tube im-
mediately after cessation of an air leak and lung
reexpansion may result in recollapse in up to 25%
of patients [145]. For this reason, continuing pleural
drainage for an additional 24 to 48 hours following
the last evidence of any air leak may promote pleu-
ral symphysis.

9. Prior to removal, the chest tube entry site should
be cleansed, sutures freed, and sterile dressing pre-
pared. At end exhalation, the patient should per-
form a Valsalva maneuver and be warned of poten-
tial burning or pulling sensations [146]. The tube is
rapidly removed and the skin sealed with an occlu-
sive dressing [147,148] or by tightening indwelling
sutures [75,99,149], which allows healing to occur
by primary intension with less scarring. Pausing,
during tube removal or allowing the patient to
breath during removal may allow air to reenter the
pleural space and cause a recurrence of a
pneumothorax. Despite preparation, some patient
may inhale in response to pain, increasing the
chance of air reentry [40]. A follow-up chest radio-
graph should be performed at (typically within 24
hr) following chest tube removal to detect residual
or recurrent pneumothorax.
Complications
Complications from chest tube placement occur
with relative frequency, owing to the proximity of
both major vascular and visceral structures near the
insertion site and within the reach of a migrating
chest tube. Complications can be divided into
placement-, maintenance-, and discontinuation-re-
lated categories (Table 3).
Table 3. Complications Associated with Use of Chest
Tubes
Placement
Lung laceration
Intercostal artery hemorrhage
Diaphragm penetration
Phrenic nerve palsy
Heart laceration or compression
Great vessel puncture, occulusion, or erosion
Thoracic duct puncture
Injury of major extrathoracic viscera
Stomach, liver, spleen
Horner's syndrome
Extrathoracic soft-tissue placement
Maintenance
Unilateral reexpansion pulmonary edema
Empyema
Lung entrapment with focal infarction
Subcutaneous emphysema
Arteriovenous fistula formation of chest wall
Pleural reactions
Necrotizing fasciitis
Pneumothorax with inadvertent disconnection
Discontinuation
Recurrence of pneumothorax
Pleurocutaneous fistula
Retained catheters or fragments
Gilbert et al: Chest Tubes 81
Although most information regarding complica-
tions has been anecdotal, one retrospective series
of 1,249 patients with acute thoracic trauma neces-
sitating tube thoracostomy reported an overall
2.4% incidence of empyema; the majority occurred
following trocar placement [94]. The subgroup of
447 patients with placement by blunt dissection had
a 1% technical complication rate, with diaphrag-
matic perforation, lung and stomach lacerations
[94]. These are operator-related errors and likely
avoidable with proper training and technique.
Lunglaceration is more likelyto occur in patients
with poor lung compliance or pleural adhesions
(e.g., following pleurodesis, sclerotherapy, old in-
flammation) [91,92,94]. Perforation in infants may
be heralded by persistent or repeated pneumo-
thoracies despite the presence of a chest tube, or by
atelectasis or infiltrate near the end of the chest
tube [150]. Infants with severe respiratory distress
syndrome (IRDS) appear to be at particularly high
risk for this complication [151]; other risk factors
include left-sided placement, use of multiple tubes,
and gestational age less than 28 weeks [152]. Other
mediastinal structures, such as the aorta [153,154],
may be obstructed. '
Cardiogenic shock, following risk atrial lacera-
tion [90] or right ventricular compression [155], has
been reported. Chylothorax, resulting from tho-
racic duct injury, can follow left-sided tube place-
ment [156]. Intercostal artery hemorrhage resulting
from injury to the neurovascular bundle located at
the inferior surface of the superior rib is best pre-
vented by placement through the caudad-most por-
tion of the intercostal space [92]. Because the artery
becomes increasingly vermiculate with age, elderly
patients may be at greater risk for intercostal artery
puncture [157].
Diaphragmatic penetration may be an isolated
occurrence [94] or may result in laceration to the
esophagus, stomach, liver, or spleen [81,158]. The
diaphragm rises to the level of the fourth intercos-
tal space during full expiration [94]. Therefore, per-
foration is best avoided by inserting the chest tube
no lower than the fourth intercostal space (later-
ally), preferably during inspiration following blunt
dissection and digital exploration [24]. Higher
placement may result in bleeding from the pectora-
lis muscle or breast injury [94]. Ipsilateral hemi-
diaphragmatic palsy from isolated injury to the in-
trathoracic phrenic nerve has been reported
[159-161], as has contralateral hemidiaphragmatic
elevation secondary to atelectasis, with transsaggital
migration of a medially deployed tube [162].
If the tip of a chest drain is allowed to migrate to
the apex of the pleural cavity, injury to the ascend-
ing sympathetic chain at the lung cupola can result

10. 82 Journal of Intensive Care Medicine Vol 8 No 2 March-April 1993
in ipsilateral Horner's syndrome [163-166]. This in-
jury is believed to result from repeated trauma and
hematoma formation consequent to respiratory
motion. Serial chest radiographs may forewarn its
occurrence [167]. Subcutaneous emphysema,
eminating from the thoracostomy site to involve
portions of the chest wall and neck, is usually only a
cosmetic problem [88]. Air migration may result
from the inciting injury or from inability to vent
pleural air. Treatment is rarely indicated unless re-
sidual pneumothorax remains or cardiopulmonary
instability exist". Venting with skin incisions, needle
aspiration, or cervical mediastinotomy are rarely
required for tension pneumomediastinum [20].
Improper extrathoracic soft-tissue placement, al-
though usually not injurious, prevents proper evac-
uation of the pleural cavity. To avoid pleural con-
tamination, no chest tube should be advanced
further through the insertion site once placement
has been completed. Rapid reexpansion of atelec-
tatic lung may result in unilateral pulmonary edema
[168], which may be fatal [169]. Young patients and
those with large pneumothoracies appear at great-
est risk [170]. It has also been suggested that
pneumothoracies present for more than 24 hours
may predispose to reexpansion pulmonary edema.
Initial drainage by water seal has been suggested in
this situation. Edema has been attributed to either
extreme vacuum pressure exerted on the pleural
space in the face of an obstructed bronchus [171] or
simply rapid reexpansion of lung leading to sub-
acutely collapsed [169]. In the case of pleural effu-
sions, removing fluid at a rate no greater than 1 LI
hour has been advised to decrease the likelihood of
pulmonary edema [73]. If excessive pleural suction
is used, lung infarction and subsequent aspiration
into the thoracostomy tube may also occur [172].
Suction from a chest tube may potentiate pleural
effusion in patients with impaired venous drainage
[173] or induce myocardial ischemia [174].
Intrapleural infection following tube thoracos-
tomy, either from insertion [23] or the presenting
injury, ranges from 1 to 16% [29,175,176]. Most se-
ries report rates under 3% [177]. Development of
empyema is more frequent in trauma patients with
incomplete drainage, penetrating injury, or pro-
longed use [178]. Necrotizing fasciitis, attributed to
soiling from anaerobic bacteria during empyema
drainage, can be a lethal complication [179]. Rou-
tine use of prophylactic antibiotic coverage (typi-
cally first- or second-generation cephalosporins)
for prevention of infection in all patients receiving
tube thoracostomy has been empiric, costly, and
potentially dangerous [14,180,181]. Prophylaxis for
patients with thoracostomy for spontaneous
pneumothorax is probably unnecessary, although
little data are available [180]. Three offour prospec-
tive, randomized studies (clindamycin in penetrat-
ing thoracic trauma [177] and cefamandole [180] or
cefazolin [182] in both penetrating and nonpene-
trating thoracic trauma) found a four- to nine-fold
decrease in the incidence of empyema, pneumonia,
or lung abscess in antibiotic-treated patients versus
control subjects. A fourth study using cephapirin
was equivocal [181]. Intrapleural administration of
antibiotic through a chest tube for postthoracos-
tomy empyema has been described [183].
Miscellaneous complications include arteriove-
nous fistula formation within the chest wall or great
vessels [184,185], unexpected pleural reactions to a
chest tube [109], and pneumothorax following in-
advertant disconnection of the suction apparatus.
Disconnections can occur at insertion Site, drainage
device, or, more commonly, connectors or tubing.
Even simple Heimlich valves, if improperly re-
versed, can result in potentially dangerous compli-
cations, such as tension pneumothorax [186]. Com-
plications may appear after chest tube removal,
including recurrence of pneumothorax [148] and
formation of pleurocutaneous fistula tracts. Re-
tained thoracostomy tubes within the pleural cavity
have been percutaneously retrieved under fluoros-
copy with a rigid nephroscope [187].
Competency in Placement and Usage
Physiciansresponsible for placement, maintenance,
and removal of tube thoracostomies should be
properly educated and demonstrate evidence of
competency as part of a quality review or creden-
tialing process. Tube thoracostomy has been desig-
nated a mandatory skill for all physicians involved
in general surgery and emergency medicine [188-
190] and is a desirable skill for physicians in pulmo-
nary, pediatric, and critical care [191-193]. Few
general internists are taught or can perform this
skill [194,195]. Such training should begin prior to
internship (i.e., during medical school) if possible
[196]. The American College of Surgeons Advanced
Trauma Life Support curriculum includes tube tho-
racostomy as a required station [197]. Use of re-
cently deceased patient" or cadavers has been advo-
cated despite ethical concerns [198]. Nonanimal
training models for house staff have also been de-
scribed [199]. Although no specific guidelines exist,
10 to 12 observed procedures are suggested for
minimal competence in routine placement of tube
thoracostomies. Minimal training requirement for
various subspecialties may be necessary to assure
adequate experience in this invasive procedure
[193].

11. The authors thank Judy Gunther and James Kendrick of the
Biomedical Communications Department of the George Wash-
ington University for their assistance in the preparation of this
manuscript.
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