1. Introduction

a. Patient Preparation

b. Draping

c. Marking

d. Local Anesthetic

e. Tube Preparation

2. Surgical Approach

3. Incision

4. Access to Pleural Space

5. Chest Tube Insertion

6. Dressing

7. Post-op Remarks and X-Ray

The clinical presentation of pneumothorax ranges from no symptoms to life-threatening tension physiology requiring emergent intervention. The thoracic cavity is lined with parietal while the lungs and mediastinal structures are lined with visceral pleura. Normally in apposition, a potential space exists between these two layers where fluid, air, or a combination of the two may accumulate. If this potential space fills with fluid or air, subsequent collapse of the lung tissue causes symptoms such as shortness of breath and tachypnea. If the fluid or air accumulate to the degree that venous cardiac return is impeded, tension physiology ensues with hypotension, tachycardia, and eventual cardiovascular collapse if the pressure is not relieved. Tube thoracostomy remains the treatment of choice for managing pneumothorax. Here, we present the management of a traumatic pneumothorax with tube thoracostomy in a 51-year-old male injured in a motor vehicle collision. 

<h4>CHAPTER 1</h4>

<p>Our patient is a 51-year-old male who was in an MVC approximately eight hours previously. He presented to the emergency room and had a chest X-ray as part of his workup, and this is the chest X-ray that was obtained about six hours ago. As you can see, notably, that there's clearly a left-sided pneumothorax and what the arrows indicate where the lung is, clearly shrunk away from the chest wall. He subsequently underwent a chest CT - that I will pull up now, and in a four hour period, the pneumothorax increased in size. This CT was taken about four hours after the initial chest X-ray. The trauma team was consulted following this chest CT. As you can see, this is a moderate-to-large sized pneumothorax. And this chest CT was obtained approximately four hours after the initial chest X-ray, and where the pneumothorax was evident on the chest X-ray, you can see clearly, this is quite a large pneumothorax in this six-hour interval. And so following this, the trauma team was consulted, and obviously the choice - we chose to proceed with a chest tube - tube thoracostomy. So on reviewing the chest CT, obviously the pneumothorax that was evident on the chest X-ray was clear. At this point, it's a moderate-to-large sized pneumothorax, and then scrolling inferiorly, you can also see there is a component of hemothorax here that you can see. He has some lung markings here, but scrolling down, obviously that's an effusion consistent with a hemothorax in a traumatic setting. So, our goal for this tube thoracostomy - we're going to try to position this tube posteriorly and basilar to drain the hemothorax as well as deal with the pneumothorax.</p>

<h4>CHAPTER 2</h4>

<p>This patient came in earlier today, following an MVC, had a moderate-sized left pneumothorax. We are preparing to do a left tube thoracostomy. The patient was previously considered for a left tube thoracostomy, confirming that the left side of the chest was the affected side. Also, this patient's MR has been - and identity band have confirmed the patient's identity. And completing the time out, the patient received 2 g of Ancef for prophylaxis.</p>

<p>We are just starting to prep the chest here before draping. And also, he's connected to continuous pulse oximetry, telemetry, so we will take note of any vital sign changes during the procedure. And we have a multimodal pain management plan here. We're definitely going to be using Lidocaine for local anesthesia, and if needed, we have Fentanyl ready to be administered, as well as Ketamine.</p>

<p>And in our planned procedure here, we're going to go with the midaxillary line, fourth or fifth intercostal space is our intended entry site, which roughly corresponds to the level of the nipple here. We want to make sure that our draping includes the nipple just for point of reference on where we're going to enter the rib space, okay?</p>

<p>I'm going to go ahead and start with a little mark where I intend to make my skin incision, and I'll plant a tunnel up one rib space for entry into the pleural cavity.</p>

<p>All right, so we're going to get ready to inject a little bit of numbing medicine, okay? And then our goal is to create a nice locally-blocked field. Little pinch. Starting with a superficial injection and working our way down onto the rib, and also into the pleural space. And I can confirm that I'm on the rib here, so I'm going to give a little bit of local into the periosteum. We can talk about the key principles of the procedure while we're numbing up this area. We're going to be making our skin incision, and then using our Kelly for - for subcutaneous tunnel, and then when we enter the pleural space, we're making sure that we're going in the superior - over the top of the rib space to avoid the neurovascular bundle. We're still just injecting the numbing medicine, okay? Any discomfort there? Nope. Okay, good. And then I feel like I have pretty good local pain control here, but I will prepare some extra Lidocaine in the case that he's uncomfortable during the procedure.</p>

<p>Okay, we'll go ahead and prepare our tube, and we've already set up our Pleur-evac, so that it's all ready to go. And this is a pneumothorax and we do not expect much blood, but I always like to clamp the back of the tube.</p>

<h4>CHAPTER 3</h4>

<p>Okay, so I'm just making our skin incision at our planned entry site.</p>

<h4>CHAPTER 4</h4>

<p>And we're starting our subcutaneous tunnel onto the rib where we plan to enter. I'm trying to follow the same track every time. And obviously in an emergent chest tube, we're going to go much faster, but in this… How's your pain, sir? Not too much feeling. You don't feel it? Good. You don't feel pain? I don't feel too much feeling. Okay, okay. Okay, so I'm right down onto the top of the rib here. Do you think you're in the chest cavity? No, I'm in the pleural space right now. I'm in the pleural space.</p>

<h4>CHAPTER 5</h4>

<p>Let's open it up. Yep. Well! I'll probably need one more stitch. So it looks to be well-positioned in the chest. Can we have a second 0 silk stitch, please? There, cut that off. This is our tie-down. So I like to place two sutures first in a Roman sandal to tie the tube in, and the second is a U-stitch across the incision to be tied down at the time of removal. So, tie that now. Okay. Do it once more? Yep. He'll loop the silk around the tube several times and then tie it down, loop it around several times and tie it down again. Provide some friction on the tube, keep it in place. So cut this one short. Place the next stitch in a U-stitch configuration, so that at the time of closure, that's left loose and we tie it down as the chest tube is coming out. Here at the University of Chicago, this is our method for ensuring that we don't have a pneumothorax following chest tube removal. I'll cut that off for you. And throw one throw-down loosely, and then wrap the rest of this long so people know that this is the tie-down suture, and they don't inadvertently cut it. Elliot wants to close this little aspect here with a third suture, which is okay given that he made a generous incision. In the trauma patient, most often these procedures happen in an emergent setting, and we're going to make a larger incision than what our elective colleagues do. Thank you. And then we're going to get a post-procedure chest X-ray to confirm our position and to see how our pneumothorax has resolved. We're going to put our chest tube dressing on, and then we will be finished. And we can go ahead and call for X-ray.</p>

<h4>CHAPTER 6</h4>

<p>All right, and that completes the procedure.</p>

<h4>CHAPTER 7</h4>

<p>So we have completed our left-sided chest tube and we're reviewing our post-procedure chest X-ray that's just been completed. And the things that we're paying close attention to are number one, is the pneumothorax improved or resolved? And number two, is our chest tube in good position? And our goal for the chest tube was that it was posterior and basilar given the presence of the hemothorax, and as you can see our chest tube is in good position. It is a basilar tube, which explains about 100 to 150 cc's of blood that we had on placement. We'll get a morning chest X-ray, and then based on the findings, potentially water seal him and work towards getting the chest tube out. But, this is a well-placed chest tube, and hopefully the patient is going to rapidly improve.</p>

Watch this full-length, narrated surgical video of a left tube thoracostomy on a patient with a pneumothorax.

UChicago Medicine

Left Tube Thoracostomy for Pneumothorax

0299.2_StylePass_20200429

0299.2 - Chest Tube for Pneumothorax

The clinical presentation of pneumothorax ranges from no symptoms to life-threatening tension physiology requiring emergent intervention. The thoracic cavi

Journal of Medical Insight

Left Tube Thoracostomy for Pneumothorax | Journal of Medical Insight