105 Chest Tubes

Clinical Presentation

A 4-year-old female presents with high fever, cough, increased respiratory rate, bronchial breathing, and decreased breath sounds on the right side. Her pediatrician had treated her with antibiotics. She continued to deteriorate, and after a chest radiograph was performed she was referred to a pediatric tertiary care center. After admission she was further imaged with CT and ultrasonography. What interventional procedure should be performed?

Figure 105A

Figure 105B

Figure 105C

Radiologic Findings

The chest radiograph demonstrates complete opacification of the right hemithorax (Fig. 105A). Ultrasound shows a complex collection (Fig. 105B), whereas CT provides evidence of empyema with underlying lung inflammation, abscess, and likely necrosis. In addition, there is a medial enhancing fluid collection that represents either a medial loculated empyema or a mediastinal abscess (Fig. 105C).

Diagnosis

Necrotizing or aggressive pneumonia with empyema, and possible mediastinal abscess requiring chest tube placement

Discussion

Background

Chest tubes (or thoracostomy tubes) are placed in the pleura space for the drainage of air and/or fluids in the thoracic region. Chest drainage techniques have been used since the early 1900s for the treatment of postpneumonic empyema. In recent years, the traditional technique has been replaced by an image-guided technique and adjunctive intracavitary fibrinolytic therapy. The image-guided technique has the potential of reducing many of the complications associated with a “blind” placement technique, including accidental damage to the internal thoracic arteries.

Etiology/Indications for Drainage

Chest drainage is used in situations where a loss of pleural negative pressure is noted. This may have the following causes:

Persistent or recurrent pneumothorax: The first occurrence of a pneumothorax in a patient should initially be aspirated. Chest drainage should be initiated if aspiration is unsuccessful. With recurrent pneumothoraces, the associated adhesions will likely necessitate chest tube placement because aspiration is often unsuccessful in such situations.
Tension pneumothorax: Decompression and chest tube placement are usually performed blindly due to the acuity and severity of the situation.
Traumatic pneumothorax: This is an unpredictable situation, which may rapidly evolve into a tension pneumothorax. Therefore, a chest tube insertion is often the safest management.
Pneumothorax in a patient in need of positive pressure ventilation
Bilateral pneumothoraces
Hemothorax: Lack of drainage may result in empyema or a fibrothorax.
Empyema: An image-guided approach allows for a precise targeting of the collection and is especially vital in cases of a loculated empyema.
Malignant pleural effusions
Chylothorax

Clinical Findings

Clinical findings are usually related to the underlying pathology. Some common symptoms may include:

Dyspnea, the most common clinical finding
Chest pain, includes sharp pain that worsens with deep inspiration and may refer to upper abdomen or ipsilateral shoulder
Tachypnea and hypoxia
Diminished breath sounds on affected side
Hypo- or hyperresonance to percussion