The lungs are located in the thorax on either side of the heart and covered by a thin membrane called pleura. There are two layers to the pleura, and normally there is a trace amount of fluid in between the layers to allow efficient and effortless respiration.
Pleural effusion :
Any excessive fluid developed between the pleural layers is called pleural effusion.
Causes:
There are various causes for the pleural effusion, some are minor which subside on their own without any treatment. Others may require tests, analysis of the fluid for better characterization. Based on the amount of fluid and cause, some of these require definitive management either by aspiration (thoracentesis) or placement of a tube to facilitate drainage. These procedures are performed as elective or urgent depending on the amount of fluid and symptoms.
Pneumothorax:
Defined as air between the pleural layers.
When air leaks into the area between the lung and the chest wall it pushes on the lung, causing it to collapse.
Causes:
- Penetrating chest injury,
- Particular surgical procedures like cardiac or thoracic surgery
- Biopsies of lung lesions
- Damage from pre-existing lung disease like bullous disease of the lung, malignancies.
The primary symptoms of this condition are sudden chest pain and difficulty breathing. Depending on the underlying cause, and the amount of lung collapse, the management ranges from simple observation with serial chest x-rays or placement of a chest tube to decompress the air between the pleura and allow easier breathing.
Other indications for chest tube placement include:
- Pleurodesis: In cases where a basic procedure like chest tube does not resolve the pneumothorax, medications can be instilled into the pleural cavity to assist in sclerosis and management of these situations.
- Postoperative: Thoracic or cardiac surgery involves placement of chest tubes to assist in the drainage of fluid or air after the surgery.
Chest tube:
A chest tube is a hollow, flexible tube inserted into the chest which drains blood, fluid, or air. This tube is placed between the ribs and into the space between the linings of the chest cavity (pleural space), which allows maximum expansion of the lungs.
Chest tubes come in various sizes; depending on the patient’s anatomy the doctor will select a particular tube to fit the procedure.
This procedure is also referred to as chest tube thoracostomy. Depending on the presentation, this procedure could be elective or emergency.
Doctors of different specializations are trained to perform chest tube placements during an emergency. When it comes to an elective procedure or completing it with minimal risks, it is highly recommended to have the procedure performed by an interventional radiologists.
These procedures could be performed with local anesthetic only or using moderate sedation. Interventional radiologists uses the assistance of an ultrasound, fluoroscopy (X ray) and may also use the assistance of a specialized CT scan during the procedure.
Based on the underlying cause (fluid or air), patient’s hemodynamic status, expertise of the doctor performing the procedure, the patient may be positioned either sitting up or flat on the table. With imaging guidance, a needle is passed into the pleural space. A flash of fluid or aspirating of air (Bubbles) indicate correct positioning of the needle. Next, the needle is exchanged for a wire over which a chest tube is placed after dilating the tract if needed.
Once the tube is inserted, it is secured with suture and connected to a suction bottle (fluid drainage) or under water seal system (Air). After the insertion, the patient will have a chest x-ray to ensure the correct placement of the tube.
The chest tube will stay in place until all the blood, fluid, or air is drained from the chest and the lung has completely re-expanded.
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The method of this procedure is beneficial since it is minimally invasive with no surgical incision needed.
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Risks:
Though this appears as a simple procedure, it does have the risks of bleeding/infection at the insertion site, improper placement of tube, injury to the lung, and injury to surrounding organs (spleen, liver, stomach or diaphragm). Most of these are managed accordingly for example, a bleeding might be controlled with manual compression, if severe, it may require angiogram or surgery. Improper placement requires replacement of the tube.
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Post chest tube insertion, the patient will most likely stay in the hospital until the chest tube is removed. In some cases, the patient will be sent home with the chest tube. The removal of the chest tube is typically performed quickly, without sedation. In most cases, the chest tube is withdrawn as the patient is holding his/her breath to ensure that extra air doesn’t get into the pleural space. After the tube is removed, a bandage will be applied over the insertion site which may leave a small scar.
What is a chest tube?
A hollow, flexible, and plastic tube that is employed to drain fluid or air from the chest; these tubes come in a variety of shapes and sizes and have a diameter ranging from as small as a shoelace and as large as a highlighter.
What is a chest tube insertion (thoracostomy)?
Insertion of a tube into the pleural space (space between lungs and chest wall) to drain excess blood, fluid, or air in order to facilitate maximum expansion of the lung
Why do I need this procedure?
There are various indications for placement of a chest tube like explained above.
Pleural effusion: To drain excess fluid
Pneumothorax: To drain air which is causing collapse of the underlying lung.
Pleurodesis: In cases where a basic procedure like chest tube does not resolve the pneumothorax, medications can be instilled into the pleural cavity to assist in sclerosis and management of these situations.
Postoperative: Thoracic or cardiac surgery involves placement of chest tubes to assist in the drainage of fluid or air after the surgery.
How long does this procedure take?
This depends on the complexity of the presentation. Usually, this procedure is completed within 30 minutes.
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How is this procedure performed?
These procedures could be performed with local anesthetic only or using moderate sedation. The patient would be positioned either sitting up or flat on the table. With assistance of the imaging, a needle is passed into the pleural space. A flash of fluid or aspiration of air (Bubbles) indicate correct positioning of the needle. Next, the needle is exchanged for a wire, over which a chest tube is placed after, dilating the tract if needed.
Once the tube is inserted, it is secured with suture and connected to a suction bottle (fluid drainage) or under water seal system (Air). After the insertion, the patient will have a chest x-ray to ensure the correct placement of the tube.
The chest tube will stay in place until all the blood, fluid, or air is drained from the chest and the lung has completely re-expanded.
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What occurs after this procedure?
A chest x-ray will be taken to confirm accurate placement of the tube and effectiveness of the intervention.
How long will the tube remain in the patient’s chest?
The underlying cause dictates the duration of the chest tube. In most cases, the patients will need to keep the chest tube in for a few days.
When will the chest tube be removed?
The chest tube can be removed when it is no longer necessary, usually when the tube has done the job as confirmed by minimal drainage or imaging demonstrating that the fluid or air has resolved.
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What are the benefits of this procedure?
Minimally invasive: no surgical incision is necessary (only a small nick in the skin)
Diagnostic and Therapeutic.
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Who performs this procedure?
Doctors of different specializations are trained to perform chest tube placements during an emergency. When it comes to an elective procedure or to have it done with minimal risks, it is highly recommended to have the procedure performed by an interventional radiologists.
What are the risks associated with this procedure?
Risk of infection (any procedure where the skin is penetrated has this risk), accidental injury to the chest wall, arteries, veins, lung, or other surrounding organs (including, stomach, liver, spleen, diaphragm); blood clots; displacement of the chest tube; collapsed lung during tube removal.
