Thoracostomy tubes and catheters: Placement techniques and complications

INTRODUCTION — Tube thoracostomy is a common procedure in which a thoracostomy tube or catheter is placed through the chest wall into the pleural cavity to either drain an indication (eg, pneumothorax, hemothorax, effusion, empyema) or instill medication (eg, talc, doxycycline, fibrinolytic agent). Larger diameter thoracostomy tubes require a blunt dissection technique procedure for placement (figure 1), whereas smaller diameter tubes and catheters can be placed using a percutaneous technique (ie, Seldinger technique over a wire) (figure 2) and cause less pain both during and after placement. Providers who place thoracostomy tubes (diameter ≥16 French [Fr]) or thoracostomy catheters (≤14 Fr) should be privileged to perform the procedure and treat/address the potential complications and should be well versed with all the options available as well as the equipment required for their placement and maintenance. As with all invasive procedures, hospitals should ensure appropriate training prior to granting privileges.

The literature regarding techniques for thoracostomy tube or catheter placement is mostly from the adult population. Few prospective studies are available in the pediatric population, in part due to the lower need for emergency invasive thoracic procedures in children. When a thoracostomy tube or catheter is required, the techniques for insertion are the same for adult and pediatric populations; however, in children, most tubes are smaller caliber and placed more often using the Seldinger technique. (See "Thoracostomy tubes and catheters: Indications and tube selection in adults and children", section on 'Tube sizing' and 'Techniques' below.)

The techniques for placement, management, and complications of thoracostomy tubes and catheters are reviewed, making appropriate distinctions between adult and pediatric populations when important. Specific medical and surgical conditions that result in the need to perform thoracostomy for pleural drainage are reviewed separately and discussed in more detail in separate topic reviews. (See "Thoracostomy tubes and catheters: Indications and tube selection in adults and children".)

PATIENT PREPARATION

Antibiotic prophylaxis — The need for prophylactic antibiotics prior to the placement of thoracostomy tubes depends upon the clinical circumstances. Most of the evidence for antibiotic prophylaxis is in the adult trauma population. The use of universal precautions, sterile preparation of the site including a full body drape, and local anesthesia is warranted for patients of all ages.

●Spontaneous pneumothorax – Prophylactic antibiotics are not warranted for thoracostomy tubes or catheters placed in the setting of spontaneous pneumothorax or other nontraumatic indications [1-3].

●Penetrating trauma – Prophylactic antibiotics are warranted for thoracostomy tubes placed in the setting of penetrating chest trauma [3-7]. A meta-analysis of five trials that included patients with blunt or penetrating thoracic trauma found a significant reduction in the risk of empyema (relative risk [RR] 0.19, 95% CI 0.04-0.70) and pneumonia (RR 0.44, 95% CI 0.15-0.87) for patients who received antibiotic prophylaxis compared with placebo [4].

●Elective thoracic operations – In elective thoracic surgery, prophylactic antibiotic therapy is administered as a preoperative dose only (table 1). There is no evidence to support continuation of antibiotics. In a randomized trial that included 245 adults undergoing elective thoracic surgery who required thoracostomy and who received preoperative prophylactic antibiotics, patients treated with extended postoperative antibacterial prophylaxis (48 hours) had a rate of surgical site infections comparable to patients randomized to placebo (six versus five patients, risk difference -0.93, 95% CI -6.1 to 4.3) [8,9]. In total, 13 patients (10.7 percent) receiving postoperative antibiotics and 8 patients (6.5 percent) receiving placebo developed an associated infection (ie, surgical site infection, empyema, or pneumonia) by postoperative day 28 (risk difference -4.3 percent, 95% CI -11.3 to 2.7). The antimicrobial agents used for prophylaxis are reviewed separately (table 2). (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults", section on 'Thoracic surgery'.)

Patient history and examination — Prior to thoracostomy tube or catheter placement, the patient's history should be reviewed, including the clinical features pertinent to the current indication, as well as other elements of the history or physical examination that might impact tube placement. These include the following:

●Cardiomegaly

●Situs inversus

●Mediastinal tumor

●Prior thoracic surgery

●Prior thoracostomy tube or catheter placement or pleurodesis

●Presence of medical devices (eg, central venous access/port, pacemaker/defibrillator, shunt tubing, nerve stimulator)

●Bleeding diathesis

●Antithrombotic therapy

●Obesity, scoliosis, chest wall deformity

●Factors that elevate the diaphragm (eg, Trendelenburg position, pregnancy, hemoperitoneum, air in stomach/intestines from positive pressure ventilation, bowel obstruction, obesity)

●Other factors in the pediatric population include:

•Diaphragm integrity (congenital or traumatic), functionality, and height (ie, may fluctuate significantly with phases of breathing, which may be quite rapid, or from crying, hyperventilation, or anomalies [eg, trachea-esophageal fistula])

•Cysts and pulmonary abnormalities or congenital malformations that mimic pneumothorax on radiograph

•Developing breast tissue in prepubescent females

Analgesia/sedation — Thoracostomy tube or catheter insertion at any site is painful for most patients, but in emergency clinical settings, the thoracostomy tube or catheter can readily be inserted under local anesthesia (eg, 1% lidocaine) with or without an intercostal nerve block. Keep in mind the potential toxicity of lidocaine. The maximum allowable dose is 4 to 5 mg/kg without epinephrine and 5 to 7 mg/kg with epinephrine (table 3). As always, slow instillation through a small-bore needle (27 or 30 gauge) and use of buffered lidocaine help limit the pain of injection and may help to avoid pain and anxiety.

In the elective setting, oral, intranasal, or intravenous sedation can be administered prior to tube insertion, in addition to local anesthetic infiltration. Non-critically ill pediatric patients may require additional distraction techniques, emotional support, or medications to help with anxiety. Benzodiazepines (intravenous or infusion) can be quite helpful. If families or other caretakers are present during the procedure (as is often the case in pediatrics), specific emotional support may be needed to help them distract the patient and maximize the chance of a stress-free procedure. (See "Procedural sedation in children: Approach" and "Sedative-analgesia in ventilated adults: Management strategies, agent selection, monitoring, and withdrawal" and "Procedural sedation in adults in the emergency department: General considerations, preparation, monitoring, and mitigating complications".)

EQUIPMENT — The types of available thoracostomy tubes and catheters for insertion into the pleural space and selection of tube size based on indication are reviewed separately. (See "Thoracostomy tubes and catheters: Indications and tube selection in adults and children".)

The equipment needed for tube thoracostomy is listed in the table (table 4).

Thoracostomy tubes and catheters: definitions — We use "thoracostomy tube" to refer to traditional tubes, which are clear with longitudinal markers and are generally stiff, though the stiffness depends on the size of the tube, with larger tubes becoming relatively stiffer. Larger diameter thoracostomy tubes (≥16 Fr) require a surgical cut-down procedure for placement. We refer to these as "surgically placed thoracostomy tubes."

We use "thoracostomy catheter" to refer to smaller diameter (≤14 Fr) tubes or flexible opaque specialty tubes (eg, pigtail). Thoracostomy catheters and smaller diameter thoracostomy tubes can be placed over a wire using a Seldinger technique [10]. We refer to these as "percutaneously placed thoracostomy catheters" or "percutaneously placed thoracostomy tubes."

Approach to placement by size of tube — The way a thoracostomy tube or catheter is placed depends upon the stiffness of the tube and its diameter.

Most clinicians insert a larger diameter thoracostomy tube (≥16 Fr) with an open surgical technique. The open technique uses blunt dissection to access the pleural space. Thoracostomy tube trays that contain most of the required instrumentation (except the tube itself) are commonly though not universally available. Although some hospitals still carry and some clinicians still use a sharp trocar to aid in the insertion of a thoracostomy tube, we believe the trocar method should never be used since this technique significantly increases the risk of organ perforation [11]. (See 'Blunt dissection technique' below.)

Smaller diameter (≤14 Fr) thoracostomy tubes and thoracostomy catheters (eg, pigtail) are typically placed using percutaneous techniques. The Seldinger technique accesses the pleural space with a needle and uses progressive dilatation of the tract over a guidewire. Commercially available kits are available that include the required equipment.

INSERTION SITE — Generally, thoracostomy tubes and catheters are placed at the fourth or fifth intercostal space in the anterior axillary or midaxillary line [11-14]. In emergency situations, the landmarks are the nipple line in males and the inframammary crease in females (figure 3). Care should be taken to avoid potential damage to developing breast tissue in prepubescent females. Electively placed thoracostomy tubes, especially those designed to drain effusions, may be placed one to two rib spaces lower, or as low as possible in the chest with the use of ultrasound guidance, and may be tunneled in thin patients. Care must be taken to ensure the tube enters the pleural cavity. The technique for using ultrasound to guide the placement of a catheter to drain pleural effusion is discussed elsewhere. (See 'Role of ultrasound or other imaging' below and "Ultrasound-guided thoracentesis".)

The thoracostomy tube or catheter insertion positioning within the pleural cavity depends on the indication for tube placement; fluid collects in the dependent portion of the chest cavity, whereas air collects in the nondependent portion. For tubes placed in the anterior or midaxillary position, the tube should be directed anteriorly for air drainage or posteriorly for fluid drainage to keep the tube from tracking between the lobes, as could occur if passed straight in patients who have complete fissures. If this happens, the tube may become walled off by the lung and fail to drain the pleural air. A tube placed for fluid is likely more effective if it is lower in the chest. For draining a hemopneumothorax, the thoracostomy tube or catheter is directed posteriorly because the priority is to drain the blood and monitor blood loss.

A potentially better site for patients with only a pneumothorax is the second intercostal space in the midclavicular line. The anterior approach requires placing the tube through the pectoralis muscle. We recommend this approach only for a pneumothorax that is clearly seen on imaging and when a small thoracostomy catheter (eg, 10 to 14 French pigtail) is used, rather than a larger thoracostomy tube placed via the fourth or fifth intercostal space in the anterior axillary line. For patients with a simple, uncomplicated pneumothorax, placement via the anterior midclavicular approach is associated with reduced pain at the insertion site and can be performed at the bedside for most patients [10].

ROLE OF ULTRASOUND OR OTHER IMAGING — Ultrasound or other imaging modalities (eg, fluoroscopy, computed tomography) can be used to guide thoracostomy tube or catheter placement. Placing a thoracostomy tube or catheter can be associated with severe complications, including damage to the lung, diaphragm, heart, liver, or spleen. The use of thoracic ultrasound can minimize complications, and ultrasound also accurately identifies the location of pneumothorax by an absence of lung sliding on two-dimensional and M-mode imaging [15]. In the nonurgent setting, ultrasound is preferred when loculated effusion or adhesions from prior surgery are anticipated.

Ultrasound can localize a fluid collection and image the lung to help prevent lung laceration during tube placement. For pleural fluid drainage, the proposed site of thoracostomy tube or catheter insertion can be confirmed by first performing a thoracentesis using ultrasound guidance. If air or fluid is not obtained during diagnostic thoracentesis, the insertion site is reassessed by reviewing the available chest radiographs or computed tomography. Occasionally, fluid may not be able to be aspirated with a small needle because of high viscosity of the pleural fluid. (See "Imaging of pleural effusions in adults" and "Bedside pleural ultrasonography: Equipment, technique, and the identification of pleural effusion and pneumothorax" and "Ultrasound-guided thoracentesis".)

TECHNIQUES — Thoracostomy tubes or catheters can be inserted directly into the chest cavity through an incision or by using the Seldinger technique, which places the tube over a wire. These approaches are discussed separately below. (See 'Blunt dissection technique' below and 'Seldinger technique' below and 'Needle thoracostomy' below.)

Providers who place thoracostomy tubes or catheters should be well versed in all the options available and the potential complications and have privileges to perform this procedure at their home institution. In addition, as these are commonly placed in the emergency department, a plan should be in place for who will manage the tube once the patient is admitted. As with all invasive procedures, hospitals should ensure appropriate training prior to privileging. This procedure may be one where a facility or medical team requires participants to document competency on a recurring basis (eg, observation, simulation). The use of thoracic ultrasound can minimize complications, and ultrasound also accurately identifies the location of pneumothorax by an absence of lung sliding on two-dimensional and M-mode imaging as well as the location and amount of any pleural fluid.

Prior to thoracostomy tube or catheter placement, a pre-procedure timeout should confirm the side of placement by review of the radiographic studies to avoid placement on the wrong side.

Blunt dissection technique — The open technique for thoracostomy tube placement is typically used to drain an effusion or hemothorax, more typically in older adolescents and in adults.

●For patients who are hemodynamically stable, attention should be paid to providing adequate pain control for this procedure with local anesthetic infiltration and the use of appropriate sedation (if feasible). Supplemental oxygen is provided as needed. (See 'Analgesia/sedation' above.)

●Prepare the skin around the area of insertion, preferably with chlorhexidine. Thoracostomy tubes should be placed with full barrier precautions (gloves, gown, mask, eye protection, hair covering) and, whenever possible, full body drapes.

●Using local anesthesia with attention to the maximum dose for the size of the patient, infiltrate a small area of skin (2 to 3 cm in adults) and subcutaneous tissue one intercostal space below the intercostal space that will be used to place the tube (figure 4). (See "Subcutaneous infiltration of local anesthetics" and 'Analgesia/sedation' above.)

As an example, if the thoracostomy tube will be placed in the fifth intercostal space, anesthetize the skin overlying the sixth intercostal space. This allows the creation of a tunnel of subcutaneous tissue through which the tube will be placed, which helps to prevent reentry of air when the tube is removed. However, for thoracostomy tube placement in emergency circumstances, or in adults with obesity, tunneling is not required and doing so may increase the risk of subcutaneous tube placement.

●Make a small incision (2 to 3 cm in adults) in the skin at the site of the lidocaine injection parallel to the intercostal space. Aspirate prior to injecting the local anesthetic to ensure that it is not being injected intra-arterially into the intercostal artery. Anesthetize the periosteum of the rib above and the rib below the planned intercostal insertion site and include the muscular tissue of the intercostal space. Attempt to direct lidocaine to the area of the parietal pleura where the tube will enter the pleural space. The lower rib margin is avoided to prevent injury to the neurovascular bundle.

●Using an appropriately sized curved clamp (eg, hemostat, Kelly), bluntly dissect and create a short subcutaneous tunnel from the incision site cephalad toward the intercostal space through which the thoracostomy tube will be inserted. Grasp the Kelly clamp with one hand controlling the handle and the other braced on the patient and holding the clamp near its tip to avoid plunging the clamp deep into the patient's chest (figure 1).

●With the clamp in a closed position, push the clamp over the superior portion of the rib (to avoid injury to the neurovascular bundle that runs along the inferior aspect of the rib) and through the parietal pleura. Open the clamp to spread the intercostal muscles and parietal pleura. In infants and children, when applying pressure, the chest wall will deform significantly due to rib flexibility and the relatively cartilaginous rib cage. One must be prepared for a need for significant pressure when placing the clamp, followed by a rapid/sudden decrease in pressure when the pleura is punctured. Safeguards, such as positioning the index finger near the tip to limit the clamp's entry, are imperative to avoid lung damage from inadvertent deep puncture.

●Insert a finger through the tract into the pleural space to confirm proper position and make sure there are no adhesions between the lung and the pleural surface. Only easily disrupted adhesions should be lysed with the operator's finger because dissection may cause significant bleeding if more organized adhesions are torn. It is also very important to realize that lung parenchyma adherent to the chest wall can be mistaken for pleural adhesions. Although the visceral pleura has significant structural integrity, once it is violated, the lung parenchyma is easily torn. Sweeping a finger through the lung can lead to significant bleeding and air leak, possibly requiring surgical intervention to repair. If the operator is not expecting significant adhesions but encounters them, the site should be abandoned. If the patient is stable, chest imaging and consultation with thoracic surgery or interventional pulmonary service should be considered. If additional imaging is unable to be obtained and urgent placement is needed, using a more caudal rib space (by one or two ribs) may allow for safe placement of the tube in adult patients with non-traumatic indications. For trauma patients and pediatric patients, a more cephalad placement is preferred to avoid possible injury to the diaphragm, which is more likely to be elevated, or potential infra-diaphragmatic (intra-abdominal) placement.

●Clamp the thoracostomy tube at the insertion end with the clamp. With the aid of the clamp, insert the tube through the tract into the pleural space and direct it either apically for a pneumothorax or inferiorly and posteriorly for a pleural effusion. As a general rule, tubes that track anteriorly are better for draining air, and tubes that track posteriorly are better for draining fluid.

●Remove the clamp and confirm that the thoracostomy tube is in the thoracic cavity by observing condensation within the tube with breathing, or drainage from the tube. Advance the tube until the last drainage hole is fully within the thoracic cavity for children and inside by at least 2 cm for adults.

●Place a suture to anchor the thoracostomy tube, loosely tying over the tube and then tying firmly around the tube, enough to avoid dislodgement but not tight enough to obstruct the tube (if the incision was large, an additional suture may be needed to close the incision) (picture 1). The more distal tube can be secured to the skin of the chest or back to prevent the tube from pulling on the stitches, which is painful and might lead to dislodgement of the tube.

●Following thoracostomy tube placement, obtain a chest radiograph to confirm tube position and assess lung expansion. Make sure that the gap in the radiopaque marker that marks the tube drainage hole closest to the skin is within the pleural space. As an adjunct, ultrasound performed by an experienced operator can be used to determine the adequacy for pleural fluid removal or to assess lung re-expansion. (See 'Role of ultrasound or other imaging' above.)

●Monitor the initial drainage from the tube. If the lung has been in a state of significant compression due to a large effusion or pneumothorax, the clinician must be aware of the possible complication of re-expansion pulmonary edema and be prepared to treat it. Provided the patient does not have an acute hemothorax and there is no significant air leak, it is reasonable to clamp the tube for a period of time if a patient starts coughing while fluid is draining from a newly placed thoracostomy tube. Allow the patient's cough to subside before removing more fluid. (See 'Managing initial drainage' below and 'Re-expansion pulmonary edema' below.)

Seldinger technique — The Seldinger technique (figure 2) is useful for the placement of smaller-bore thoracostomy catheters that drain air and nonviscous fluids and is typically performed with the aid of ultrasound or fluoroscopy to confirm the placement and positioning of the wire or catheter within the chest cavity (figure 5). (See 'Role of ultrasound or other imaging' above.)

In the setting of a large pneumothorax or large effusion where radiographic imaging has confirmed that the lung is significantly displaced from the chest wall at the planned entry site, it may be safe to place these tubes without imaging guidance; however, if there is any doubt, imaging guidance or standard tube placement should be performed. (See 'Role of ultrasound or other imaging' above and 'Blunt dissection technique' above.)

A disadvantage of this technique is the inability to assess the presence of adhesions between the lung and pleural surface during tube insertion. If the introducer needle and guidewire are inserted into an area of dense pleural adhesions, the catheter may inadvertently pass into the lung parenchyma. However, awareness of previous medical/surgical history and the use of ultrasound before and during tube insertion should minimize this potential complication. (See 'Role of ultrasound or other imaging' above.)

Once the site is prepared and anesthetized, we proceed as follows (figure 5):

●Insert an introducer needle into the pleural space (over the rib) and confirm that either fluid or air can be aspirated. If neither fluid nor air is aspirated, do not proceed. In this case, review the images again and consider a different site for insertion.

●If fluid or air is returned, insert the guidewire through the introducer needle into the pleural space. The wire should pass without resistance; if resistance is encountered, the procedure should be abandoned. Direct the guidewire apically for a pneumothorax or inferiorly and posterior for a fluid collection. Guidewire position can be verified with fluoroscopy, if available.

●Pass the dilators sequentially over the guidewire to dilate the tract. This will require a small nick in the skin to assist in passing the dilators.

●Pass the thoracostomy tube or catheter and dilator combination into the pleural space.

●Remove the dilator and guidewire, leaving the thoracostomy catheter in place, ensuring that all the holes are within the chest cavity. For some kits, the dilator is removed and then the catheter is placed over the wire directly. Draw back on the catheter and reconfirm that either fluid or air is returned.

●Properly secure the catheter (suture, commercial tube holder), dress with gauze, connect the drainage system, obtain a chest radiograph to confirm its position and assess lung expansion, and monitor the initial drainage from the tube as described above. It is common practice, but not necessary, to place petrolatum gauze around the catheter. In the authors' experience, this can cause problems such as macerating the skin, which may lead to infection after catheter is removed. Devices are available for fixation of thoracostomy tubes or catheters that eliminate the need for sutures. In our experience in the adult population, such devices risk dislodgement of the tube; however, there may be a role for these in the pediatric population. (See 'Blunt dissection technique' above.)

Needle thoracostomy — The hemodynamically unstable patient with a suspected tension pneumothorax needs immediate decompression with the quickest method available. This can be either with a thoracostomy or catheter (eg, pigtail), or angiocatheter. Simply inserting the introducer needle will release the pressure from tension physiology, stabilizing the patient. Needle thoracostomy can be performed on the affected side at the fifth intercostal space midaxillary line or in the midclavicular line through the second intercostal space with one of any readily available kits, a long angiocatheter (adult, pediatric), or the introducer needle for a pigtail catheter. While the 10^th edition Advanced Trauma Life Support (ATLS) guidelines recommend needle decompression from a lateral approach in adults, others support decompression and thoracostomy tube or catheter placement via the anterior approach [16]. For patients who will require transportation, an anterior site may be more stable and easier to monitor. (See "Initial evaluation and management of penetrating thoracic trauma in adults", section on 'Role of needle/finger chest decompression'.)

The angiocatheter from the kit is placed first, which allows for immediate decompression. Because these catheters are small-bore thin-walled catheters, they are prone to kinking, and they may not completely relieve a tension pneumothorax. They can also be dislodged, leading to reaccumulation of air and recurrent tension pneumothorax. Thus, immediately following needle decompression, a thoracostomy tube or catheter should be placed, the diameter of which depends upon the expected pathology. As an example, for spontaneous pneumothorax, an appropriately sized catheter (eg, ≤14 French pigtail) can be placed immediately over a wire into the pleural space using a modified Seldinger technique. Alternatively, a larger thoracostomy tube can be placed, as described above. (See 'Seldinger technique' above and 'Blunt dissection technique' above.)

Following needle thoracostomy, the needle/catheter is attached to a syringe (5 or 10 mL in adults) and is inserted along the superior margin of the third rib in the midclavicular line or over the fifth rib in the midaxillary line. For adults, in our experience, a standard-length 14- to 16-gauge angiocatheter is nearly always successful; however, patients with obesity will need a longer catheter for adequate penetration of the chest. Such catheters are also effective in children, but a smaller needle/catheter is used in neonates and young children. As an example, a 20 or 22 gauge catheter ranging from 1.0 to 1.88 inches (2.54 to 4.77 cm) long is more appropriate for neonates and children to avoid injury to the lungs and surrounding structures. Butterfly needles can also be used in neonates.

Once the catheter has been placed, the needle is withdrawn and the angiocatheter is initially left open to air. An immediate rush of air out of the chest indicates the presence of a tension pneumothorax, which has now been converted to a large but simple pneumothorax. Tubing can be attached to the angiocatheter and the open end placed into a bottle of sterile water, which should be placed below the insertion site to avoid fluid being pulled into the pleural space; bubbles indicate the flow of air. This is a temporizing measure to emergently address an air leak that may be acutely problematic or is anticipated to rapidly reaccumulate. A definitive tube for continued drainage can then be placed in a less emergent fashion.

Catheter length should be chosen based upon the body habitus of the patient. In a systematic review that included 13 studies, a catheter length of 6.44 cm (2.54 in) would ensure that 95 percent of the patients would have adequate penetration to the pleural space during needle thoracostomy [17]. In another study of 604 male patients and 170 female patients, mean chest wall thickness was 3.50 cm (2.17 in) at the left second intercostal space at the midclavicular line, and 3.51 cm (2.18 in) on the right [18]. The mean chest wall thickness was significantly higher for females compared with males. A chest wall thickness greater than 4.5 cm (2.79 in) was present in up to 35.4 percent of females and 19.3 in males, respectively. In a comparative study of adults (age >15 years), a longer (8 cm; 3.14 in) compared with shorter (5 cm; 1.96 in) needle was associated with a significant improvement in success rates (83 versus 41 percent) [19].

DRAINAGE SYSTEMS — Wet or dry suction control, closed-drainage systems are typically used, and each is effective for draining pleural air and fluid. Unidirectional flutter valves, which allow the patient to remain ambulatory, can be used in patients who have small pneumothoraces with minimal or no air leak or nonviscous malignant pleural effusions.

The configuration and function of a typical wet-control, closed-drainage system (eg, Pleur-evac) is detailed in the figure (figure 6A-B). Other closed-suction systems are available that allow the patient to be mobile (figure 7). Ad hoc ("improvised") systems can be used as a temporary measure, with sterile water in a small container to mimic a water seal, without suction [20]. It is important that the fluid container be placed below the catheter to avoid inadvertent suction of fluid into the pleural space.

Thoracostomy tube or catheter drainage systems usually incorporate a pressure release valve that rapidly equilibrates the collection chamber pressure with atmospheric pressure without disconnecting the suction tubing. This feature can be used if the patient develops chest pain as a result of too rapid an evacuation of large pneumothoraces or pleural effusions. (See 'Managing initial drainage' below and 'Re-expansion pulmonary edema' below.)

Initial level of suction — The typical initial level of suction used in the clinical setting is -10 to -20 cm H₂O of water (adult and pediatric populations), which can be adjusted if there is failure to drain. Commercial closed-drainage systems typically allow the suction level to be adjusted between 0 and -40 cm of water.

The level of suction used depends upon the indication. Suggested initial suction levels are given below:

●For spontaneous air leaks, the least amount of suction (including none [ie, water seal]) needed to maintain full expansion of the lung is appropriate. There is no evidence to support the routine initial use of suction in the treatment of spontaneous pneumothorax [21]. We suggest starting on water seal (ie, no suction). If there is incomplete resolution of the pneumothorax, then we initiate suction at -10 cm of water and increase the amount of suction only as needed, as determined by the chest radiograph. A persistent air leak without complete re-expansion is the usual reason for applying (or increasing) suction [22].

●When the thoracostomy tube or catheter is placed for fluid drainage, -20 cm of water is a reasonable place to start, and the level of suction should be increased as indicated with the goal of achieving full lung expansion as determined by the chest radiograph. For a collapsed lung due to pneumothorax or copious pleural effusion, large differential pressure gradients should be avoided during lung re-expansion to prevent re-expansion pulmonary edema (RPE). When placed for a large pleural effusion, we suggest no suction initially, a step that may decrease the risk of re-expansion pulmonary edema [23]. (See 'Managing initial drainage' below and 'Re-expansion pulmonary edema' below.)

●Following lung resection surgery and initial postoperative suction, whether ongoing suction applied to the thoracostomy tube improves or worsens pleural leaks is controversial. This issue is discussed separately. (See "Overview of pulmonary resection", section on 'Chest tube placement and management'.)

●For thoracostomy tubes placed for thoracic trauma, few data are available to guide the best initial level of suction. Early studies suggested that suction improved expansion of the lung and prevented retained hemothorax [24]. However, a randomized trial comparing initial suction with no suction following penetrating or blunt chest trauma found no significant advantages for suction [25].

Managing initial drainage — The amount of thoracostomy drainage should be assessed on a regular basis (hourly, in the setting of trauma).

●With traumatic hemothorax, in general, an immediate drainage of 20 mL/kg or the accumulation of >3 mL/kg per hour of blood is an indication for thoracotomy to identify and manage thoracic vascular injury. Fluid resuscitation and a decision for thoracotomy are discussed in detail separately. (See "Overview of blunt and penetrating thoracic vascular injury in adults" and "Thoracic trauma in children: Initial stabilization and evaluation".)

●For large-volume effusions, the rapid removal of large volumes has been associated with RPE. (See 'Re-expansion pulmonary edema' below.)

•In the absence of an active air leak, to minimize the likelihood of developing RPE, we recommend clamping the thoracostomy tube or catheter to stop removing fluid if the patient develops severe coughing, chest pain, shortness of breath, or oxygen desaturation after thoracostomy tube placement. Before resuming drainage in either case, we wait until any symptoms have resolved. Even without symptoms, for patients without any signs of a mediastinal shift from the effusion, we limit initial fluid drainage (1.5 liters in adults, 20 mL/kg in children) by clamping the thoracostomy tube or catheter and waiting at least one hour before draining additional fluid. Patients with mediastinal shift contralateral to the tube or catheter may tolerate a larger amount of initial fluid removal, because a certain amount of fluid can be removed to return the mediastinum to midline before the lung starts to reinflate. The risk of RPE begins when the lung starts to reinflate [26].

•In the rare case of a large effusion and an active air leak, the tube cannot be clamped. However, to decrease the risk of RPE, the drainage tube can be draped from the insertion site to a level above the patient's head and then back to the drainage system, which is ideally situated on the floor. This creates a fluid trap that allows air to safely escape but slows the drainage of fluid.

MORBIDITY AND MORTALITY — Morbidity and mortality from thoracostomy tube or catheter placement are related to the experience and training of the clinician, the indication for placement, and the circumstances under which the tube is placed (ie, elective versus emergency) (table 5) [27,28]. Complications of thoracostomy tube or catheter placement include malposition, infection (eg, empyema, pneumonia), intercostal nerve or artery injury, organ injury (eg, lung, diaphragm, heart, liver, or spleen), and pulmonary edema related to re-expansion pulmonary edema (RPE). The risks of thoracostomy tube insertion in children are considered the same as those for adults, though overall estimates of the rate of injury in children may be higher, with several publications reporting rates as high as 30 percent (table 5 and algorithm 1) [29-31].

Death is not common, but between 2003 and 2008, there were 17 fatalities in the United Kingdom directly related to the insertion of the thoracostomy tube or catheter in adults [32]. The overall incidence of complications in adults ranges from 1 to 6 percent and is related to the diameter of the tube, with small-bore tubes having fewer complications [33-36]. However, the incidence of blockage is higher with small-bore tubes. In one study of 126 thoracostomy tube or catheter placements by pulmonologists at a teaching hospital, the majority of complications were related to clotting, kinking, or dislodgement, which were noted in 8 percent of the patients [37]. More significant complications (eg, pulmonary laceration) occurred in an additional 3 percent of patients. Rare complications, including intercostal artery aneurysm and cardiac compression leading to cardiogenic shock, have also been reported [38,39].

Thoracostomy tube or catheter malposition — Thoracostomy tube or catheter malposition is the most common complication of tube placement [40-42]. Thoracostomy tubes or catheters that are malpositioned may represent a form of penetrating trauma and should be managed accordingly. Consultation with a pulmonary or thoracic surgery service should be strongly considered before making any changes in a stable patient with a tube that is malpositioned. As an example, an intraparenchymal thoracostomy tube or catheter should not be removed until a second functioning thoracotomy tube or catheter has been placed into the pleural space. The clinician should be prepared to manage bleeding, as well as a potentially immediate massive air leak, when the malpositioned tube is removed. Without a second functioning tube in place, tension pneumothorax could arise very quickly.

In one study of 77 thoracostomy tubes urgently placed in 51 adult trauma patients, malpositioning was detected in 20 (26 percent) with chest computed tomography (CT) [42]. Nine tubes were intrafissural, five were intraparenchymal, and two were subcutaneous. Location (intraparenchymal versus intrafissural) could not be determined for four tubes. Persistent pneumothorax (including two tension pneumothoraces) and hemothorax were associated with 16 of the 20 (80 percent) tube malpositions. Only one of the five intraparenchymal tubes was diagnosed by chest radiograph, and only four of the nine intrafissural tubes were suspected on chest radiograph. Thus, a CT scan should be obtained if a patient's plain film or clinical course is consistent with tube malposition (eg, thoracostomy tube or catheter is not draining).

Infection — Pneumonia and empyema complicate the course of thoracostomy tube or catheter placement in 1 to 3 percent of patients. Increasing duration of tube or catheter placement and retained hemothorax increases the risk of infection, which is more common in patients sustaining penetrating chest trauma [5,43]. The early evacuation of retained hemothorax decreases the incidence of empyema, and chest CT is more useful than plain films in making a determination of who should be treated [44]. (See "Inpatient management of traumatic rib fractures and flail chest in adults", section on 'Empyema'.)

Organ injury — The most commonly injured organ with thoracostomy tube or catheter placement is the lung, reported in 0.2 to 1.4 percent of insertions. Perforation of other organs, including the heart, spleen, liver, stomach, colon, and diaphragm, have all been reported [11,12,45-50]. Perforation of mediastinal structures and death are more likely when entry into the chest using the needle, angiocatheter, or clamp is not controlled. (See 'Techniques' above.)

Recognition of perforation of the lung as a result of thoracostomy tube or catheter placement may also be delayed, with autopsy studies noting pulmonary perforations that were not suspected antemortem [51,52].

Re-expansion pulmonary edema — RPE is an uncommon but potentially life-threatening complication of tube thoracostomy that usually arises after rapid re-expansion of a lung that has been collapsed for at least three days due to either pneumothorax or effusion. From an early report, RPE was reported to be more likely after drainage of pneumothorax [53]; however, in later publications, RPE has been associated more with drainage of pleural effusions [54-56].

Retrospective reviews report an incidence between 0 and 1 percent in adults [54-56]. RPE remains a rare occurrence in the pediatric population [57-59].

●In one review, the occurrence of 27 RPE cases among 172 adult patients treated for spontaneous pneumothorax correlated to the duration and size of the pneumothorax and not to suction settings [60].

●A review of the literature identified only 22 pediatric cases with RPE, with approximately 50 percent occurring postoperatively [58].

Patients developing RPE typically present soon after thoracostomy tube or catheter placement with cough, dyspnea, and hypoxemia, but the clinical presentation can be delayed for up to 48 hours. Suggestions for prevention include avoiding suction for expansion of spontaneous pneumothorax and limiting initial fluid drainage [58,61]. (See 'Managing initial drainage' above.)

While the pathophysiology related to RPE is unclear, some studies suggest an elevated pleural gradient that can occur when performing removal of large volumes of pleural fluids associated with the development of RPE. These studies suggest that use of pleural manometry may be useful in reducing the risk of the development of RPE, and not allowing the gradient to exceed 17 cm H₂0 [62].

Treatment is supportive (eg, positioning, positive pressure ventilation, fluid restriction), and the disease is usually self-limited [23]. In a review of pediatric cases, no specific treatment was noted or recommended [58]. The commonly quoted mortality rate of 20 percent comes from one small review [53]. Later and larger series report a mortality rate of less than 5 percent in adults [54-56]. The diagnosis and management of RPE are discussed in detail elsewhere. (See "Noncardiogenic pulmonary edema", section on 'Re-expansion pulmonary edema'.)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Pneumothorax (collapsed lung) (The Basics)")

PATIENT PERSPECTIVE TOPIC — Patient perspectives are provided for selected disorders to help clinicians better understand the patient experience and patient concerns. These narratives may offer insights into patient values and preferences not included in other UpToDate topics. (See "Patient perspective: Lymphangioleiomyomatosis (LAM)".)

SUMMARY AND RECOMMENDATIONS

●Thoracotomy tubes and catheters – Thoracostomy tube (diameter ≥16 French [Fr]) or thoracostomy catheter (diameter ≤14 Fr) placement into the pleural cavity is performed to drain abnormal collections of air or fluid or as a means of instilling agents (eg, talc). Indications include pneumothorax, hemothorax, and pleural effusion, including malignant effusion, chylous effusion, parapneumonic effusion, and empyema. Providers who place thoracostomy tubes or catheters should be privileged to perform the procedure and should be well versed with all the options available and the potential complications, as well as the equipment required for their placement and maintenance. (See 'Introduction' above.)

●Imaging before placement – For patients with adhesions from infection, previous pleurodesis, or prior pulmonary surgery, a computed tomography scan of the chest should be obtained to guide thoracostomy tube or catheter placement. Blind insertion of a thoracostomy tube or catheter is dangerous in these patients. (See "Thoracostomy tubes and catheters: Indications and tube selection in adults and children", section on 'Relative contraindications' and 'Role of ultrasound or other imaging' above.)

●Prophylactic antibiotics

•For patients with penetrating thoracic trauma, we recommend administering prophylactic antibiotics prior to thoracostomy tube or catheter placement (Grade 1B). Rates of empyema and pneumonia are significantly decreased when antibiotics are given prior to thoracostomy tube placement. No consistent reduction in infectious complications has been found in patients with blunt thoracic injury or nontraumatic indications for tube thoracostomy; thus, prophylactic antibiotic treatment in these populations is not necessary. (See 'Antibiotic prophylaxis' above.)

•For patients undergoing elective thoracic surgery requiring a thoracostomy tube, we suggest administering preoperative prophylactic antibiotics only, rather than extending coverage into the postoperative period (Grade 2C). (See 'Antibiotic prophylaxis' above.)

●Device selection and site – The choice of thoracostomy device, including its size, shape, and insertion site, depends upon the indication for placement (ie, nature of the fluid to be drained) and size of the patient. (See "Thoracostomy tubes and catheters: Indications and tube selection in adults and children", section on 'Tube definitions and types'.)

●Techniques – Two techniques are commonly used for placement of thoracostomy tubes and catheters following appropriate preparation and local anesthetic administration. Needle thoracostomy is used as a temporizing, life-saving measure for patients with tension pneumothorax. (See 'Techniques' above.)

•Standard technique – The standard technique uses a small incision on the chest wall and blunt dissection to access the pleural space to place a thoracostomy tube. A sharp trocar should not be used to access the pleural space; the trocar can cause mediastinal injury and fatal exsanguination. (See 'Blunt dissection technique' above and 'Organ injury' above.)

•Seldinger technique – The Seldinger technique uses a needle to access the pleural space and place a guidewire over which a thoracostomy catheter is placed. (See 'Seldinger technique' above.)

•Needle thoracostomy – In hemodynamically unstable patients in whom there is a high suspicion for tension pneumothorax, needle thoracostomy should be performed as a lifesaving (albeit temporizing) measure by reducing the intrapleural pressure and restoring venous return to the heart. Following needle decompression of the chest, a thoracostomy tube or catheter should be placed as soon as possible because needle thoracostomy may not completely relieve the tension pneumothorax and technical issues may lead to recurrent tension pneumothorax (Grade 2C). (See 'Needle thoracostomy' above.)

●Preventing re-expansion pulmonary edema – RPE is a life-threatening complication that is usually due to the rapid expansion of a large pneumothorax, but it can also follow rapid drainage of large volumes of pleural fluid in patients with chronic lung collapse. (See 'Managing initial drainage' above and 'Re-expansion pulmonary edema' above.)

•In the absence of an active air leak, to minimize the risk for RPE, we suggest limiting the initial drainage (1.5 liters in adults, 20 mL/kg in children) (Grade 2C).

•In the rare case of a large effusion and an active air leak, the tube or catheter cannot be clamped. However, to decrease the risk of RPE, the drainage tube can be draped to a position above the patient's head and then back to the drainage system, which is ideally situated on the floor. This creates a fluid trap that allows air to safely escape but slows the drainage of fluid.

●Drainage systems – Dry and wet suction control and closed-drainage systems are both effective for draining pleural air and fluid. Unidirectional flutter valves can be used in selected patients to allow the patient to remain ambulatory. The level of suction used depends upon the indication. (See 'Techniques' above and 'Drainage systems' above.)

●Complications – The most common complication is malposition of the tube or catheter. Other complications are rare but include infection (eg, pneumonia, empyema), organ injury, and RPE. Death attributed to the procedure is uncommon. (See 'Morbidity and mortality' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Peter Doelken, MD, FCCP, who contributed to earlier versions of this topic review.