A chest tube (chest drain, thoracic catheter, tube thoracotomy, or intercostal drain) is a flexible plastic tube that is inserted through the chest wall and into the pleural space or mediastinum. It is used to remove air (pneumothorax), fluid (pleural effusion, blood, Chile), or pus (empyema) from the intrathoracic space. It is also known as a Bülau drain or an intercostal catheter.
The concept of chest drainage was first advocated by Hippocrates when he described the treatment of empyema by means of incision, cautery, and insertion of metal tubes. However, the technique was not widely used until the influenza epidemic of 1918 to drain post-pneumonic empyema, which was first documented by Dr. C. Pope, on "Joel", a 22-month-old infant. The use of chest tubes in postoperative thoracic care was reported in 1922, and they were regularly used post-thoracotomy in World War II, though they were not routinely used for emergency tube thoracostomy following acute trauma until the Korean War
. Viral pneumonia presents more commonly with wheezing than bacterial pneumonia. Pneumonia was historically divided into "typical" and "atypical" based on the belief that the presentation predicted the underlying cause. However, evidence has not supported this distinction, therefore it is no longer emphasized.
The most common complication of a chest tube is chest tube clogging. Chest tube clogging is widely recognized in published surveys of surgeons and nurses. In one study, 100% had seen chest tube clogging, and a majority had seen adverse patient outcomes from chest tube clogging. In a prospective observational study, over 36% of patients had chest tube clogging after heart surgery. Chest tube clogging can lead to retained blood around the heart and lungs that can contribute to complications and increase mortality. If a chest tube clogs when the patient is still bleeding they can become hypotensive from tamponed, or develop a large hem thorax. If there is not enough to cause mechanical compression of the heart or lungs, the resulting inflammatory response to the retained blood can lead to pleural and pericardial effusions and contribute to the triggering of postoperative atrial fibrillation in susceptible individuals.
A common complication after thoracic surgery that arises within 30–50% of patients is air leaks. If a chest tube clogs when there is an air leak the patient will develop a pneumothorax. This can be life-threatening. Here, digital chest drainage systems can provide real-time information as they monitor intra-pleural pressure and air leak flow, constantly. Keeping vigilant about chest tube clogging is imperative for the team taking care of the patient in the early postoperative period.
Major insertion complications include hemorrhage, infection, and reexpansion pulmonary edema. Injury to the liver, spleen or diaphragm is possible if the tube is placed inferior to the pleural cavity. Injuries to the thoracic aorta and heart can also occur.
When chest tubes are placed due to either blunt or penetrating trauma, antibiotics decrease the risks of infectious complications.
Minor complications include a subcutaneous hematoma or seroma, anxiety, shortness of breath, and cough (after removing a large volume of fluid). In most cases, the chest tube-related pain goes away after the chest tube is removed, however, chronic pain related to chest tube-induced scarring of the intercostal space is not uncommon.
Subcutaneous emphysema indicates backpressure created by undrained air, often caused by a clogged chest tube or insufficient negative pressure. If a patient has subcutaneous emphysema, it is likely their chest tube is not draining and consideration should be given if it should be unclogged or another tube should be placed so that the air leaking from the lung can be adequately drained.
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Journal of lung