Incorrect placement of a chest drain 1
Even when chest drain placement has been performed according to intrathoracic findings, “special” topographic localization is rarely required. One should assess the potential future need for additional therapy when deciding on the diameter of the tube. Drains that are placed very posteriorly may initially have a sufficient therapeutic effect but can lose efficiency as the patient leans on it (kinking), adding pain and potential infection risk. There should always be a discussion with the patient before any procedure concerning the current disease, indication, risks/benefits, and therapeutic alternatives as issues can occur such as pain due to access-related trauma to the musculature.
The complication rates and their severity after drain insertion (particularly the so called Trocar drains) are well studied [34]. This textbook recommends and therefore explains the blunt dissection technique for the placement of a chest drains as a result of these studies.
The use of trocar drains is associated with a significant increase in complications and should therefore be avoided.
7.3 Technical Problems When Inserting a Drain
- 7.3.1
When a trocar drain is used, there is an increased rate of incorrect placement in an extrathoracic or subcutaneous position [24] due to the drain gliding off the ribs. The frequency of misplaced drains can be reduced by using the blunt insertion technique.
False placement of a chest drain 2
- 7.3.2
The placement of the chest tube may become more difficult if the chest wall is unstable due to several rib fractures or if rib segments are missing. When placing a chest drain for a traumatic indication, special attention to the imaging is crucial to avoid placing the tube next to jagged bone. This could result in cutting of the tube or persistant pain that is difficult to treat.
False placement of a chest drain 3
- 7.3.3
Subcutaneous emphysema can range from a discrete radiological finding to annoyance of the patient, to massive swelling causing impairment of respiratory mechanics and pacemaker malfunction [25]. Emphysema can be caused by:
Pulmonary leakage with a mismatch of “produced” air and drainage capacity (i.e. in patients on the ventilator.
Disproportionate large incision in the parietal pleura allowing air from the chest cavity to pass into the intercostal and subcutaneous tissue bypassing the tube.
Insufficient placement of the intrapleural drain (i.e. interlobar)
Insufficient placement of the chest tube where the sentinel hole is not within the chest cavity (i.e. hole in the subcutaneous tissues)
Insufficient suction capacity due to kinked tubes (subcutaneous or extrathoracic, “forgotten“clamps) or clogged drains (blood, fibrin, tissue) [38]. Treatment is based on the removal of the obstacle(s), insertion of additional drain(s), or modification of the drainage strategy.
Tension pneumothorax due to clamping
False placement of a chest drain 4
Nasal or oral oxygen administration may accelerate absorption of subcutaneous emphysema. Procedures to relieve emphysema, such as transdermal aspiration or subcutaneous drain placement, are infrequently necessary.
- 7.3.4
Insufficient fixation of the drain and/or sealing of the incision can lead to skin irritation, pain, and poor efficiency of the drain. Also the development of wound infections and pleural empyemas are promoted. Daily dressing changes and wound evaluation is mandatory to diagnose an infection or any loosening of the tube fixation as early as possible. Drain dislocation, intrathoracic erosion, air leaks, and moist wound conditions may be prevented using tight suture techniques and nonabsorbable sutures.
Insufficient fixation of a drain
7.4 Injuries Specific to an Organ
Not all somatic complications are avoidable when performing invasive procedures. Nevertheless a meticulous review of the clinical situation, imaging, and the patient related anatomy is mandatory. An individualized approach to any technical procedure minimizes potential risks. In the following chapters complications are discussed as they correspond to particular anatomical findings.
7.4.1 Injuries of the Chest Wall
Injuries to the intercostal arteries can cause life threatening bleeding [37]. Although the communicating posterior intercostal arteries arise from the aorta and the anterior intercostal arteries arise from the internal mammary arteries this by no means ensures that they run as expected in the sulcus costalis at the lower edge of the ribs. With advanced age, the arteries descend further inferiorly towards the intercostal space. This lower positioning is pronounced in the area near the paravertebrals (4 cm) with increasing tendency towards the lateral position (9 cm) and must be taken into consideration in all diagnostic and therapeutic aspirations in elderly patients [54].
With increasing age, the intercostal arteries (in particular posterior and lateral) no longer run in the sulcus costalis but may be located in the intercostal space and thus can be harmed when entering the chest through the intercostal space.
There are anatomical variations where collateral arteries at the lateral chest wall (mainly between the 8th and 11th intercostal spaces) cover two to three intercostal spaces. This is also seen inferiorly/superiorly at the fourth to seventh intercostal spaces on the right side [11, 23, 52].
Injuries to the intercostal vessels as well as their subsequent branches or to the A. thoracica lateralis may lead to excessive bleeding requiring surgery.
Chest wall hematoma 1
Injuries to the vasculature are usually evident during the procedure. Venous injuries may remain undetected due to compression by the chest tube until the drain is removed [44]. Bleeding into the chest cavity with resultant anemia and hemothorax can lead to significant morbidity and mortality.
Late complications are seen even after several years such as arteriovenous fistulas that require surgery or embolization [19].
When choosing the subaxillary “safe triangle”, potential injuries to the latissimus dorsi muscle and the vessel/nerve bundle can be avoided. Damages to these structures can cause hematomas and/or functional limitations like scapula alata [17].
Chest wall haematoma 2 + 3
More anterior localization can lead to issues of the breast including mastitis, pain, and complications with breast implants (i.e. a silicone-leak or silicothorax if disrupted) [41].
Soft tissue infections (see drain fixation) include those caused by pathogenic “routine germs” such a Staph. aureus up to very serious cases of necrotizing fasciits [9, 21]. The latter might be difficult to differentiate in the presence of subcutaneous emphysema. Once recognized this is a surgical emergency requiring immediate intervention and antibiotic therapy. “Simple” wound infections can usually be cured with local treatment and may disappear after drain removal without systemic therapy. Erosion of ribs with consecutive osteomyelitis is very rare.
Sterile and an atraumatic surgical technique are fundamental principles for prevention of infection. There is no clear evidence to support prophylactic periinterventional administration of antibiotics. These antibiotics are mainly used in the emergency setting especially with penetrating chest trauma.
Damage to lung parenchyma can be caused by a soft tissue infection that is propagated along the chest tube. The chest tube can act as a “guardrail” from the extrathoracic space into the chest cavity. Insufficient evacuation of traumatic hemothoraces can lead to the development of blood clots and a restrictive pulmonary rind [12, 26]. In those patients, early thoracoscopic intervention to prevent empyema is recommended.
7.4.2 Damage of Lung Parenchyma
The organ most frequently injured during the insertion of a chest drain is the lung due to numerous reasons. The use of a chest drain with insufficient guidance along the inner convex surface of the chest wall can direct it in a perpendicular direction [34]. This can lead to injuries of the lung parenchyma as well as insufficient tube placement in the fissure.
Injury of the lung parenchyma 1 + 2
Postinflammatory or postoperative adhesions are usually identified by sufficient preinterventional imaging (X-ray, CT scan) and taken into account when placing the drain.
In ventilated patients the lung does not develop atelectasis after opening of the parietal pleura and therefore the lung tissue does not fall away from the palpating finger. This can lead to parenchymal damage [13] which can be avoided by using short breaks in ventilation or apnea to insert the drain.
A cerebral air embolism can occur in ventilated patients after traumatic perforation of lung tissue or the intraparenchymal placement of a drain [5]. A lack of differential diagnostic considerations of this complication and the variable clinical symptoms may mask the real incidence of this complication.
A Broncopleural fistula may be an indication for chest drain insertion. To determine the correct diagnosis, CT scan, bronchoscopy, and bronchography may be used. Depending on the findings, treatment can be conservative after placement of a chest tube, endoscopic (endobronchial placement of valves, fibrin glue), or involve surgery.
Secondary parenchymal damage can be caused by insufficient fixation of the tube or an excessive application of suction [40].
Misinterpretation of bullous emphysema as a pneumothorax is a special instance where iatrogenic damage of lung parenchyma can be caused by placing a drain into the bulla. If there is any diagnostic doubt of disease, advanced imaging with a CT scan is mandatory.
Misinterpretation of bullous emphysema as a pneumothorax can lead to a prolonged air leak that frequently requires surgical intervention. A CT scan is mandatory if there is any doubt concerning the correct diagnosis.
Injury of the lung parenchyma 3
Often damage of lung parenchyma is not noticed initially and later detected when high flow and/or insufficient drainage is observed. To avoid (tension) pneumothorax or extensive subcutaneous emphysema, a new drain should be placed prior to the removal of the original tube. Additional treatment will be dictated by the clinical course and may include continued current therapy or surgical repair of the damaged parenchyma (i.e. by a thoracoscopic intervention).
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