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Summary

A tube thoracostomy is a surgical procedure in which a tube is inserted into your pleural cavity to remove excess fluid, air, or blood. Pleural cavity is a thin space formed by the membranes that cover the lungs and line the inside of the chest wall. The two membranes glide against each other as you inhale and exhale. This gliding movement is lubricated by a thin film of fluid present in the pleural cavity. However, certain diseases and conditions result in the build-up of air, fluids, or blood in the pleural cavity interfering with the normal functioning of lungs. 

Depending on your condition, it may take a few hours or days to completely drain the excess fluids and air. from your pleural cavity The surgeon will ask you to stay at the hospital until the drainage is complete or discharge you with the chest tube. You will need to undergo several chest X-rays after insertion of the tube to help the surgeon monitor your drainage. Once the drainage is complete, the tube is removed by a simple procedure wherein the surgeon will gently pull out the tube while you hold your breath.

  1. What is a tube thoracostomy?
  2. Why is tube thoracostomy recommended?
  3. Who can and cannot get a tube thoracostomy?
  4. What preparations are needed before tube thoracostomy?
  5. How is tube thoracostomy done?
  6. How to care for yourself after tube thoracostomy?
  7. What are the possible complications/risks of tube thoracostomy?
  8. When to follow up with your doctor after a tube thoracostomy?
Doctors for Tube thoracostomy

Tube thoracostomy, a minimally invasive surgery, involves the insertion of a thin, plastic tube into the pleural cavity of the chest to remove excess fluid, air, or deliver medicines.

Our lungs are covered by a thin membrane called visceral pleura and the inside of the chest wall is lined by a membrane called parietal pleura. These two membranes are separated by a thin space called the pleural space or cavity. The inner surfaces of the two pleural membranes glide against each other while breathing. This movement is facilitated (lubricated) by a thin film of fluid present in the pleural cavity.

Certain diseases and conditions (injury, surgery) can result in the build-up of excess fluid, blood, or air in the pleural cavity that may compress the lungs and cause difficulty in breathing. Tube thoracostomy is performed in such conditions to drain excess fluids, air, or blood from the pleural space, allowing the lungs to expand and help facilitate breathing. The procedure may be performed in isolation or during open-chest surgery.

Chest tubes are available in a variety of diameters, ranging from as thin as a shoelace to as wide as a highlighter. The tube is externally connected to a bottle containing sterile water. The water prevents the backflow of drained fluids or air. In some cases, this tube will be connected to a suction pump to assist in drainage. Chest tube is also used to deliver medicines into the pleural cavity. Although a hospital stay is usually required until the drainage is complete, you may be discharged with the chest tube.

The surgery is recommended in the following conditions:

You may not be able to undergo this surgery if you have:

  • Pleural symphysis (fusion of the pleura, the two membranes around the lungs)
  • Coagulopathy
  • Pulmonary disease
  • Diaphragmatic hernias
  • Pulmonary adhesions (formation of bands of tissue between the pleura) from a previous surgery

Before the surgery, you will be asked to share the following details with the surgeon:

The doctor will perform a physical examination and ask you to undergo the following tests:

Your surgeon will review your details and provide you with the following instructions to prepare for the surgery:

  • Discontinue blood thinners like aspirin, warfarin, or ibuprofen a few days before the surgery.  The surgeon will provide you with a list of medicines that you can take until surgery.
  • Avoid smoking a few weeks before the surgery if you are a regular smoker.
  • If the procedure is performed under general anaesthesia (a sleep-inducing medicine), you will need to fast from midnight prior to the surgery.
  • Ask someone to drive you home following the procedure.
  • You will sign an approval form if you agree to the procedure.

After you arrive at the hospital, the hospital staff will provide you with a hospital gown. They will measure your body temperature, heart rate, and blood pressure, and insert an intravenous (IV) line in your arm. You will be asked to take medicines to prevent pain, infection, and nausea during the surgery.

The procedure is performed with a combination of IV sedative and local anaesthesia (numbing medicine); you will be awake during the procedure. However, general anaesthesia is used in some cases. If the procedure is conducted after open chest surgery, you will be already asleep.

Tube thoracostomy involves the following steps:

  • You will sit in a comfortable position or lie on the operating bed with one arm over your head.
  • The surgeon will perform a chest ultrasound to find and mark a safe site in your chest to insert the chest tube.
  • You will be connected to devices that measure your oxygen level, blood pressure, heart rate, and pulse during the surgery.
  • The surgeon will administer a sedative through the IV line to make you feel drowsy.
  • He/she will clean the marked area and inject local anaesthesia to numb the area to be operated.
  • Next, the surgeon will make a small incision (cut) in the numbed area.
  • He/she will then gently move apart the muscles and skin of your chest wall and insert a chest tube through this cut into your pleural cavity.
  • In some cases, the surgeon first inserts a wire through a needle to act as a track for insertion of the tube. You may feel some pressure or tugging sensation during this process.
  • Finally, the surgeon will secure the chest tube in place with stitches, and cover the operated site with an airtight sterile dressing.

The procedure lasts for around 30 to 45 minutes. Once the chest tube is secured, the surgeon will connect it to a plastic container placed on the floor. If required, the bottle will be connected to a suction pump to assist in drainage. You will need to continue your hospital stay until the chest tube is removed.

In some cases, patients are discharged with the chest tube and a portable drainage system. Depending on your condition, the chest tube will stay in place for anywhere between a few hours to days to completely drain the excess fluids. If you choose to continue your hospital stay, you will be given the following instructions to take care of the chest tube:

  • You will undergo a chest X-ray immediately after the surgery to confirm that the chest tube is inserted in the intended location. Several chest X-rays will be performed during your subsequent days at the hospital to ensure that the fluids are draining well.
  • If you experience pain after surgery, you will be given painkillers at regular intervals.
  • The surgeon will measure your lung capacity using a device called a spirometer.
  • While moving around with the drainage bottle, you should hold it below the waist level to keep the fluid from going back into your chest.
  • Stay close to the bed if the drainage bottle is connected to a suction pump.
  • Inform your nurse if you feel that the tube is dislodged or experience chest pain.

Once the excess fluids, air, or blood is drained from the pleural cavity, the nurse will remove the chest tube by a simple procedure that takes a few seconds. After removing the dressing, you will be asked to take two deep breaths and then hold your breath while a nurse gently pulls out the tube.

Once the chest tube is removed, your nurse will tightly pull the stitches to close the incision. However, if the size of the tube is small, stitches will not be needed; instead, the wound will be allowed to heal naturally. Finally, the nurse will cover the operated site with a dry dressing.

If you are discharged with the chest tube, you will need to take care of yourself in the following manner:

  • Take antibiotics and painkillers as prescribed.
  • Keep the skin around the operated area dry and clean. You can wash the area with water and soap.
  • You can shower; however, avoid swimming or bathing in a tub.
  • Keep the tube insertion site covered with a clean bandage.
  • Keep the drainage container below the chest level at all times.
  • Follow the surgeon’s instructions to empty the drainage container before it gets full. To empty the container, you may need to:
    • Pull out the fluids from the container with a clean syringe 
    • Dump it into the toilet
  • While lying on the bed, change your position frequently. 
  • Exercise regularly or as recommended by the surgeon.
  • Maintain a journal to record the amount of fluid-filled in the drainage container.

When to see the doctor?

Contact your surgeon immediately if you experience the following symptoms:

  • Fever
  • Chest pain
  • Trouble breathing
  • Bandage over the incision is soaked in blood
  • The tube breaks or comes out
  • Pain, redness, or swelling around the tube insertion area

The surgery carries the following risks:

  • Infection
  • Injury to the lungs or other nearby organs (heart, diaphragm, liver, etc.) and blood vessels
  • Pain during and after insertion of a chest tube
  • Formation of blood clots
  • Bleeding from the insertion site
  • Internal bleeding (into the pleural cavity or abdomen)
  • Chest tube falls out or gets dislodged
  • Improper placement of the chest tube

If the chest tube is removed during your hospital stay, you will have to visit your surgeon seven days after the procedure to get the stitches removed. A chest X-ray will also be conducted at the time to ensure that the fluids or air have not refilled the pleural cavity.

If you are discharged with a chest tube in place, your surgeon will provide you with a schedule for follow-up appointments to: 

  • Perform chest X-rays and monitor the drainage
  • Remove the chest tube and stitches

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.

Dr Shubham Mishra

Dr Shubham Mishra

Pulmonology
1 Years of Experience

Dr. Deepak Kumar

Dr. Deepak Kumar

Pulmonology
10 Years of Experience

Dr. Sandeep Katiyar

Dr. Sandeep Katiyar

Pulmonology
13 Years of Experience

Dr. Rajendra Bera

Dr. Rajendra Bera

Pulmonology
16 Years of Experience

References

  1. Radiological Society of North America (RSNA) [internet]. Oak Brook. Illinois. USA; Chest Tube Placement (Thoracostomy) and Pleurodesis
  2. O' Rahilly, et al. Basic Human anatomy. Dartmouth College [Internet]. New Hampshire. US; Chapter 22: The pleurae and lungs
  3. National Health Service [Internet]. UK; Empyema
  4. D'Agostino HP, Edens MA. Physiology, Pleural Fluid. [Updated 2020 Sep 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan
  5. Oxford University Hospitals [internet]: NHS Foundation Trust. National Health Service. U.K.; Chest drain/tube insertion
  6. American thoracic society [Internet]. New York. US; Chest tube thoracostomy
  7. American Lung Association [Internet]. Illinois. US; Chest Tube Procedure
  8. Cleveland Clinic [Internet]. Ohio. US; Pneumothorax
  9. Raja AS. Thoracic trauma. In: Walls RM, Hockberger RS, Gausche-Hill M, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed. Philadelphia, PA: Elsevier; 2018:chap 38.
  10. Moore SM, Pieracci FM, Jurkovich GJ. Chest wall, pneumothorax, and hemothorax. In: Cameron JL, Cameron AM, eds. Current Surgical Therapy. 12th ed. Philadelphia, PA: Elsevier; 2017
  11. Light RW, Lee YCG. Pneumothorax, chylothorax, hemothorax, and fibrothorax. In: Broaddus VC, Mason RJ, Ernst JD, et al, eds. Murray & Nadel’s Textbook of Respiratory Medicine. 6th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 81.
  12. Brigham Health [Internet]. Brigham and Women's Hospital. Massachusetts. US; What are empyema and lung infection?
  13. University of Rochester Medical Center [Internet]. University of Rochester. New York. US; Pleural Tumors
  14. Children's Hospital of Philadelphia [Internet]. Pennsylvania. US; Chylothorax
  15. Ravi C, McKnight CL. Chest Tube. [Updated 2020 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan
  16. Hernandez A, Sherwood ER. Anesthesiology principles, pain management, and conscious sedation. In: Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 20th ed. Philadelphia, PA: Elsevier; 2017:chap 14
  17. Guy's and St. Thomas' Hospital: NHS Foundation Trust [Internet]. National Health Service. UK; Having a chest drain inserted
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