Perioperative management - Chest drainage, open insertion in Bülau technique

primary spontaneous pneumothorax (>2cm on the X-ray image)

• Pneumothorax under ventilation
• Iatrogenic (CVC placement, pleural puncture)
• Tension pneumothorax
• Persistent or recurrent pneumothorax
• Secondary pneumothorax in patients older than 50 years
• Malignant pleural effusion
• Parapneumonic effusion or pleural empyema
• Chylothorax: after injury to the thoracic duct
• Traumatic hemopneumothorax
• Postoperative thoracic drainage

Relative to the vital threat none. Otherwise coagulation disorders; diaphragmatic hernias with intrathoracic displacement of abdominal organs

Ultrasound: Thoracic ultrasound has gained increasing importance in recent years. In all studies, ultrasound is superior to chest X-ray in sensitivity with almost the same specificity. Especially the diagnosis of a ventral pneumothorax is hardly possible with conventional X-ray and comparatively easy with ultrasound.

In the examination for pneumothorax, the pleural sliding below the intercostal space is depicted. For simplifying the representation and documentation of findings, the use of M-Mode (Motion-Mode) is suitable here. In M-Mode, a vertical sound line is recorded over time. According to the recommendation of the expert commission, 2 ventral sections (2nd and 4th ICR parasternal) and 2 lateral sections (4th and 6th ICR mid-axillary line) should be examined.

Ultrasound is also superior to chest X-ray for depicting pleural effusions. During the examination, a suitable drainage position can be determined and marked at the same time.

Chest X-ray in Expiratory PositionNote Inspiratory images are not suitable for ruling out a pneumothorax! On the usual a.p. chest X-rays, a ventral pneumothorax can often only be suspected. Radiologically, pleural effusions appear differently in supine images than in standing images, as the fluid “spills out”.

Chest CT: In patients with lung disease with chronic COPD, pulmonary emphysema, or clinical suspicion of pleural empyema, performing a computed tomography is justified. Also in patients with extensive subcutaneous emphysema, diagnosis using X-ray or ultrasound is often not possible.

In case of vital threat due to the given clinical picture, the clinical diagnosis is sufficient for indication, in this case, further diagnostics are dispensed with!

If possible (e.g. in pleural effusion) no anticoagulants should be administered during a period
of 8 hours before placement of the thoracic drainage!

• Lung injury
• Injury to intercostal nerves and vessels
• Injury to intra-abdominal and intrathoracic organs
• Emergency thoracotomy
• Fistula formation
• Infection
• Bleeding
• Subcutaneous emphysema
• Reexpansion edema or pneumonitis