Perioperative management - Tube thoracostomy, open

Primary spontaneous pneumothorax (>2 cm on the radiograph)

• Pneumothorax during ventilation
• Iatrogenic (central venous catheter placement, thoracentesis)
• Tension pneumothorax 
• Persistent or recurrent pneumothorax 
• Secondary pneumothorax in patients older than 50 years
• Malignant pleural effusion 
• Parapneumonic effusion or pleural empyema
• Chylothorax: Following injury of the thoracic duct
• Traumatic hemopneumothorax
• Postoperative chest tube

Considering the life-threatening condition: None. Otherwise, coagulation disorders, diaphragmatic hernias with intrathoracic herniation of intraabdominal organs.

Clinical findings – Pneumothorax

Expiratory chest radiograph

Note: Inspiratory chest radiographs are not suitable for ruling out a pneumothorax! In standard AP radiographs, an anterior pneumothorax can often only be suspected; perform a CT study in suspected cases (see below)! In terms of radiographic anatomy, pleural effusions present differently in recumbent radiographs compared to erect radiographs because in the former view the fluid “spills out.”

Ultrasonography Effusion detection and volume estimation.

Chest radiographs Anterior pneumothorax and loculated pleural effusion often may be demonstrated only by computed tomography. It is always indicated in clinically suspected pneumothorax with unremarkable recumbent chest radiographs (when erect radiographs are impossible).

If the specific clinical picture is life-threatening, the clinical diagnosis suffices to establish the indication; in this case, no further diagnostics are carried out!

If possible (e.g., in pleural effusion), do not administer anticoagulants within 8 hours before tube thoracostomy!

• Lung injury
• Injury to intercostal nerves and vessels
• Injury to intraabdominal and intrathoracic organs
• Emergency thoracotomy
• Fistula formation
• Infection
• Bleeding
• Emphysema
• Reexpansion pulmonary edema or pneumonitis

Local anesthesia whenever the patient has not received deep analgosedation. Local anesthesia must also include the periosteum of the rib in the region of the planned access route as well as the pleura; possibly venous access when additional analgosedation is required.

• Supine
• Arm on the affected side positioned over the head
• Other arm tucked at the side

In Abhängigkeit des Befundes stehen Operateur und instrumentierende OP-Pflegekraft beide auf der zu operierenden Seite. Die instrumentierende OP-Pflegekraft steht links des Operateurs.

Chest tube selection:

• Pneumothorax Tube size 20-24 Fr
• Pleural effusion/hemothorax: Tube size 28-30 Fr

Dressing forceps
Scalpel
Blunt scissors
Anchoring suture
Gauze squares
Water seal

Postoperative analgesia: Nonsteroidal anti-inflammatory drugs usually suffice; if necessary, they can be enhanced by opioid analgesics.
Follow this link to PROSPECT (Procedures Specific Postoperative Pain Management)

This link will take you to the International Guideline Library.

Monitoring of the tube: In correctly inserted chest tubes the water level in the collection chamber moves synchronously with the patient’s ; air escapes when a pneumothorax is being decompressed. Persistent “bubbling” in the collection chamber indicates either a continued air leak or an improperly attached connector in the tube system. If in persistent air leaks the tube suddenly stops collecting air , tube occlusion, which would result in tension pneumothorax, must be ruled out (lavage with bladder syringe + NaCl 0.9% as an emergency measure).
While blood clots may repeatedly block the tube, this can often be resolved by milking out the tubing toward the collection chamber.

Postoperative care: Varies depending on the indication:
in pneumothorax:
Leave the chest tube under suction (15-20 mmHg) for 3-5 days, then remove the suction and take a follow-up radiograph; if no pneumothorax is evident: Disconnect for 4 hours and repeat the chest radiograph
If radiographic findings are negative: Remove the chest tube.
If the radiographic findings are positive, leave the suction in place for 12 hours and repeat the suction removal.
In case of persistent pneumothorax: Surgical or thoracoscopic pleurodesis or pleural abrasion.

in hemothorax:
Drainage volume >1200 mL per day: Stop the source of bleeding surgically
Drainage volume <100 mL/day: Remove the chest tube. After removing the tube always take a chest radiograph!

Tube removal:

Careful disinfection, then U-stitch suture around the tube (e.g., Mersilene 2-0). Preplace the  knot and hold the suture ends under tension. The tube is removed by a second person while the patient exhales. Simultaneously tighten the knot while closely apposing the edges of the wound and apply a sterile dressing.

Deep venous thrombosis prophylaxis: Depending on the disease; administration of low-dose heparin is quite enough in active young patients with a spontaneous pneumothorax.
Note: Renal function, HIT II (history, platelet check)

This link will take you to the International Guideline Library.

Ambulation: Immediately; ensure adequate analgesia to avoid shallow breathing

Physical therapy: Breathing exercises in elderly patients to prevent pneumonia.