Thoracostomy

Thoracostomy
	A tube thoracostomy unit
Specialty	Pulmonology
ICD-10-PCS	Z46.82
MeSH	D006468
MedlinePlus	002947
eMedicine	80678

A thoracostomy is a small incision of the chest wall, with maintenance of the opening for drainage.[1] It is most commonly used for the treatment of a pneumothorax. This is performed by physicians, paramedics, and nurses usually via needle thoracostomy, manually using the provider's finger (simple/finger thorocostomy),[2] or with a thoracostomy tube (chest tube).

A thoracostomy is often confused with thoracotomy, which is a larger incision commonly used to gain access to organs within the chest.

Medical uses

When air, blood, or other fluids accumulate in the pleural cavity it may be drained by thoracostomy. Whereas air in this space (pneumothorax) may be released by needle thoracostomy, other substances require drainage with a thoracostomy tube.[3]

Contra-indications

There are no absolute contraindications to thoracostomy. There are relative contraindications (such as coagulopathies); however, in an emergency setting these are outweighed by the necessity to re-inflate a collapsed lung by draining fluid/air from the space around the lung.[3]

Technique

A primary skin incision is made superiorly to the rib to avoid the neurovascular supply that runs inferiorly to the rib. The surgeon will tunnel their way through the subcutaneous tissue and muscle to make their way into the pleural cavity. This cavity is where a hemothorax or pneumothorax would accumulate. Confirmation of being in the pleural cavity is done and the chest tube is placed. The chest tube is then connected to a Pleur-evac for continuous drainage. A Roman sandal tie and U-Stitch are done to secure the chest tube and to ensure that removal of the tube will not produce another pneumothorax. Chest x-ray is performed post-procedure to confirm placement and to check for resolution of the pneumothorax/hemothorax.[4]

Chest tubes are designed to collect this drainage and prevent anything from leaking back into the pleural space. This is accomplished by a check valve, usually part of a specialized drainage system with an underwater seal. Depending on the amount of air/fluid to be drained, the collection bottle may need to be periodically changed.[3]

Risks/complications

Rare complications are mostly due to placement technique, inexperience of the interventionist, and emergent vs. elective circumstances. The most common complications are recurrent pneumothorax (incomplete recovery, but an expected course), infection, and organ injury (due to mechanical damage).[5]

Esophageal injury is rare. If saliva and chyme contents drain from the chest tube, that should raise suspicion of esophageal injury. The main treatment of esophageal injury is surgical repair. The stomach is also rarely injured. Proper technique and not using a trocar during the procedure decreases the risk of this from occurring.[5]

References

Dorland, W. A. Newman (2009). Dorland's pocket medical dictionary (28th ed.). Philadelphia, PA: Saunders/Elsevier. ISBN 978-1-4160-3420-9.
https://www.jems.com/2014/03/28/simple-thoracostomy-moving-beyond-needle/
Nicks, Bret A.; Manthey, David (2011). Pneumothorax. Tintinalli's Emergency Medicine. New York City: McGraw-Hill.
, Bishop E, Bendix P. Left Tube Thoracostomy for Pneumothorax. J Med Ins. 2020;2020(299.2) doi:https://jomi.com/article/299.2
Kwiatt, Michael; Tarbox, Abigail; Seamon, Mark J.; Swaroop, Mamta; Cipolla, James; Allen, Charles; Hallenbeck, Stacinoel; Davido, H. Tracy; Lindsey, David E. (2014). "Thoracostomy tubes: A comprehensive review of complications and related topics". International Journal of Critical Illness and Injury Science. 4 (2): 143–155. doi:10.4103/2229-5151.134182. ISSN 2229-5151. PMC 4093965. PMID 25024942.

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[1] Dorland, W. A. Newman (2009). Dorland's pocket medical dictionary (28th ed.). Philadelphia, PA: Saunders/Elsevier. ISBN 978-1-4160-3420-9.

[2] ttps://www.jems.com/2014/03/28/simple-thoracostomy-moving-beyond-needle/

[Tintinalli-3] Nicks, Bret A.; Manthey, David (2011). Pneumothorax. Tintinalli's Emergency Medicine. New York City: McGraw-Hill.

[4] , Bishop E, Bendix P. Left Tube Thoracostomy for Pneumothorax. J Med Ins. 2020;2020(299.2) doi:https://jomi.com/article/299.2

[:0-5] Kwiatt, Michael; Tarbox, Abigail; Seamon, Mark J.; Swaroop, Mamta; Cipolla, James; Allen, Charles; Hallenbeck, Stacinoel; Davido, H. Tracy; Lindsey, David E. (2014). "Thoracostomy tubes: A comprehensive review of complications and related topics". International Journal of Critical Illness and Injury Science. 4 (2): 143–155. doi:10.4103/2229-5151.134182. ISSN 2229-5151. PMC 4093965. PMID 25024942.