Perioperative management - Tube thoracostomy, open

  1. Indications

    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
  2. Contraindications

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

  3. Preoperative diagnostic work-up

    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!

  4. Special preparation

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

  5. Informed consent

    • 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 a

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