International Journal of Surgery Case Reports 108 (2023) 108416

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International Journal of Surgery Case Reports

journal homepage: www.elsevier.com/locate/ijscr

Case series

Chest tube thoracostomy: A simple life-saving procedure with potential

hazardous risks
Jay Lodhia a, b, *, Mujaheed Suleman a, Samwel Chugulu a, b, Kondo Chilonga a, b, David Msuya a, b
a
Department of General Surgery, Kilimanjaro Christian Medical Centre, P O Box 3010, Moshi, Tanzania
b
Kilimanjaro Christian Medical University College, Faculty of Medicine, P O Box 2240, Moshi, Tanzania

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction and importance: Chest tube thoracostomy is a simple life-saving procedure with many benefits but
Chest tube comes with significant potential morbidity. Potentially all intra-thoracic organs are at risk of possible injury as
Complications well as peritoneal.
Drainage
Case presentation: We present four patients who had chest tube thoracostomy with potential complications
Errors
fortunately were managed promptly and recovered fully.
Tube thoracostomy
Clinical discussion: Complications related to tube thoracostomy is reported up to 25 % especially when done under
emergency conditions. While the procedure is reported safe, it's associated morbidity is not well described.
Additionally, clinicians are urged to follow standard operating procedures and address the potential complica­
tions with consent to their patients.
Conclusion: Chest tube thoracostomy is an invasive life-saving procedure performed across various clinical ranks
and sub-specialties. It has potential life-threatening risks and complications therefore clinicians should be well
trained to identify such complications and address accordingly.

1. Introduction 2. Case presentation

Chest tube thoracostomy is one of the most common procedures done 2.1. Case 1
in routine clinical practice by clinicians of different ranks and sub-
specialties [1]. Chest tube insertion has been classified as a compul­ A 56-year-old male, known diabetic on regular oral medications,
sory life-saving procedure for clinicians but unfortunately it carries a sustained polytrauma to the head, chest and left leg after being involved
significant preventable morbidity [1,2]. Thoracic injury accounts for 25 in a road traffic accident. He presented with a frontal headache but no
% of all trauma deaths. Thoracic trauma is commonly managed by tube history of loss of consciousness nor vomiting with moderate chest pain
thoracostomy with an overall complication rate of up to 30 % among all associated with coughing. He was then rushed in a nearby health facility
operators [2]. Complications associated related chest tube thoracostomy where he received first aid then referred to our centre for further care.
can be categorized into insertional, positional or infective [3]. The On presentation he was alert with a Glasgow coma scale (GCS) of 15/15,
technique of chest tube thoracostomy has changed over time since its his pupils were equal, symmetrical and reacting to light. He was
first description by Hippocrates however the eventual goal of draining dyspneic and saturating at 87 % on room air and 95 % on 5 l of oxygen
the pleural cavity has remained the same [2]. Clinicians should under­ per minute. The left leg was swollen, warm and crepitus was felt on
stand safe and reliable techniques to avoid serious complications [4]. palpating the tibia hence was immediately splinted. His blood pressure
Herein we present four cases of morbidity associated with chest tube was 110/78 mmHg, a pulse rate of 100 bpm and axillary temperature of
thoracostomy and to emphasize patient safety and error prevention. 37 ◦ C. His random blood glucose read “high” and had ketones in urine
This work has been reported in line with the PROCESS 2020 criteria and was kept on DKA protocol.
[5]. On his respiratory examination, his trachea was deviated mildly to
the right, had bilateral air entry however with reduced breath sounds

* Corresponding author at: Kilimanjaro Christian Medical Centre, P. O Box 3010, Moshi, Tanzania.
E-mail address: [email protected] (J. Lodhia).

https://doi.org/10.1016/j.ijscr.2023.108416
Received 12 April 2023; Received in revised form 6 June 2023; Accepted 6 June 2023
Available online 17 June 2023
2210-2612/© 2023 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
J. Lodhia et al. International Journal of Surgery Case Reports 108 (2023) 108416

bilaterally on the lower zones. A plain chest radiograph was immedi­ Rh-positive. He was then taken for a chest X-ray which revealed bilateral
ately taken which revealed bilateral lung contusions and left sided 6th, lung contusions and a chest tube at the mediastinum (Fig. 2). CT-scan of
7th and 8th rib fractures and a chest tube was placed in the left side by the brain revealed cerebral edema with no extra-axial collections. He
general surgery trainee that drained 200mls of hemorrhagic fluid was immediately planned for a laparotomy which revealed hemoper­
(Fig. 1). itoneum of approximately 1 l, a lacerated liver at segment five which
His CBC had a normal white cell count with a hemoglobin of 11.7 g/ was repaired and the chest-tube was revised by the general surgeon on
dl. His serum electrolytes, urea and creatinine were within normal call. He was then sent to the general ward for monitoring.
range. He faired well in the ICU however control chest X-ray revealed no During his stay he faired well and control chest X-ray was normal
hemothorax but the chest-tube was seen perforating the left hemi­ hence chest tube was removed. He recovered well with no abdominal
diaphragm (Fig. 1). The chest-tube was removed and was monitored and nervous system symptoms. He was then discharged and seen at the
closely for five days whereby his vitals maintained within normal limits, outpatient clinic with no new complaints and the sutures were then
had bilateral good air entry on auscultation and was saturating at 98 % removed.
on room air. His left leg was casted by the orthopedic team for the closed
mid-tibia fracture and his blood glucose has normalized with insulin.
Patient was discharged and was reviewed two weeks later with no 2.3. Case 3
chest symptoms with normal respiratory and abdominal exam. He was
then discharged to continue follow up at orthopedic and diabetes clinics. A 66-year-old male, known hypertensive with hypertensive heart
disease and cerebrovascular accident was admitted to our centre with a
2.2. Case 2 two-week history of chest tightness, difficulty in breathing and dry
cough. Upon examination, he was fully conscious and alert, mildly pale,
A 61-year-old male presented to our emergency unit with a 19-hour dyspneic with blood pressure of 90/60 mmHg, pulse rate of 56 beats/
history of head, chest and abdominal trauma following a motor traffic min and saturating at 92 % on room air and 96 % on 2 l of oxygen. His
accident. The exact mechanism of injury was unknown and was brought lab results revealed hemoglobin of 12 g/dl, white cell count of 5.72 ×
in a confused state. He had a history of loss of consciousness following 109/l and normal platelet count of 194 × 109/l. His serum creatinine
the event for a brief period of time and had no bleeding per ears nose or was 129 μmol/l and serum urea of 4.63 mmol/l.
throat. A chest X-ray was done that revealed a right-sided pleural effusion
On examination, he was dyspnic and saturating at 85 % on room air hence a chest tube was inserted (Fig. 3). Approximately 1.5 l of straw-
and 96 % on 3 l of oxygen per minute. He was mildly pale with a GCS of colored fluid was drained and was monitored for one week until
14/15, blood pressure of 80/70mmhg, pulse rate of 120 bpm and axil­ gradual output to nil. Control chest X-ray revealed no pleural effusion
lary temperature of 36 ◦ C. An immediate eFAST scan was done which with right subcutaneous emphysema and tip of the chest tube behind the
was positive for right hemothorax and hemo-peritoneum. A chest tube pericardium and through the diaphragm (Fig. 4). Chest CT-scan was
was inserted in the right side by the surgical trainee on duty which done which revealed chest tube posterior to the right pericardial wall
drained approximately 500mls of hemorrhagic fluid. (Fig. 5). The chest tube was then removed and patient was managed
His CBC had a normal leucocyte count of 6.72 × 109/l, hemoglobin conservatively. He was kept on furosemide and digoxin then discharged.
of 11.6 g/dl and a platelet count of 128 × 109/l. His serum potassium Upon follow up after 3 weeks he had normal respiratory examination
was 3.6 mmol/L, serum sodium of 135.90 mmol/l and blood group of O with no symptoms.

Fig. 1. Plain chest X-ray showing bilateral lung contusions, trachea centrally located (blue arrow) and left sided chest tube (red arrow). (For interpretation of the
references to colour in this figure legend, the reader is referred to the web version of this article.)

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J. Lodhia et al. International Journal of Surgery Case Reports 108 (2023) 108416

Fig. 2. A: Plain chest X-ray showing bilateral traumatic lung contusions, B-C: chest X-ray showing the chest tube deep inside the thoracic cavity coursing towards the
mediastinum.

Fig. 3. Plain chest X-ray showing right sided pleural effusion. Fig. 4. Control chest X-ray showing malpositioned chest tube with the tip
piercing the diaphragm (red arrow) and right subcutaneous emphysema (yel­
low arrow). (For interpretation of the references to colour in this figure legend,
2.4. Case 4
the reader is referred to the web version of this article.)

An 18-year-old female presented with a three-week history of left

M. tuberculosis.
sided chest pain and productive cough. She reported history of chest
CT-scan of the chest revealed multiple loculations with a thickened
trauma from a fall prior to the onset of these symptoms. She was taken to
pleura in the left hemithorax with the chest tube seen in the lung pa­
a nearby health centre where a chest tube was inserted which drained
renchyma (not in the loculation). A finding suggestive of a thoracic
pus and referred for further management. On initial presentation she
empyema with a misplaced chest tube (Fig. 6). Bilateral axillary and
was alert, mildly pale, dyspneic on oxygen saturating at 97 %, blood
paratracheal lymphadenopathy observed with a moderate pericardial
pressure of 127/70 mmHg and pulse of 100 beats/min. On respiratory
effusion was also noted. She was then transfused with two units of whole
examination a chest tube on the left side but no oscillation appreciated
blood and control hemoglobin of 9.7 g/dl. The chest tube was then
and whitish pus discharge seen around the chest tube insertion site.
revised and irrigated. She is being managed with chest physiotherapy
Trachea slightly deviated to the right side and no air entry with dull
and draining approximately 100 mls of pus. She was also kept on intra-
percussion note throughout the left side. Her CBC revealed leucocytosis
venous Gentamycin according to culture and sensitivity.
of 13.7 × 109/l, anaemia of 6.7 g/dl and thrombocytosis of 706 × 109/l.
She was then taken for a thoracotomy by the consultant surgeon of
Her serum creatinine was 42 μmol/l, urea of 3.57 mmol/l with potas­
which revealed multiple pus pockets, thick yellow pus in the parietal
sium and sodium within normal range. The pus was tested negative for
pleura, very thick parietal pleural layer adhered to the visceral pleura.

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J. Lodhia et al. International Journal of Surgery Case Reports 108 (2023) 108416

Fig. 5. CT-scan showing course of the chest tube posterior to the right pericardial wall (red arrows). (For interpretation of the references to colour in this figure
legend, the reader is referred to the web version of this article.)

procedure performed across many clinical units; as an emergency and

elective [4]. The nature being invasive comes with potential risks and
complications. Clinicians are urged to understand the risks and address
them to the clients. In this era of transparent information and value-
based healthcare, robust and competent medical training enforcement
enhances patient experience and satisfaction [4].
The overall complication rate of chest tube thoracostomy is up to 37
%, and it is reported that complications associated with tube thoracos­
tomies increase length of hospital stay and increased hospitalization
costs [6]. There are numerous complications of the procedure. Being an
invasive procedure, pain is common from the parietal pleura therefore
clinicians should administer adequate local analgesia and maintain
throughout to achieve pain-free chest physiotherapy. Tube can also
dislodge if they are not well secured or used inappropriate smaller sizes
compared to the patient's body habitus [7].
The ultimate goal of chest tubes is to drain unwanted substances
(blood, pus, fluid, air) from the pleural cavity therefore blockage is a
potential risk therefore tube size selection is vital. Thick fluids like pus
and blood require large bore tube, or even two tubes, whereas air and
serous fluids of small amounts can be managed by smaller caliber tubes
[8]. Other common complications are recurrent or residual pneumo­
thorax, air leak and incorrect placement of the tube i.e., into the sub­
Fig. 6. CT-scan showing multiple pus loculations in the right hemithorax
(yellow arrows) with chest tube malpositioned within the lung parenchyma cutaneous plane. Other less common complications as stated by Chan
(red arrow). (For interpretation of the references to colour in this figure legend, et al. are injury to intra-thoracic organs like esophagus, lungs and the
the reader is referred to the web version of this article.) atrium of the heart as seen in case 4 whereby the tube was mispositioned
into the lung parenchyma [9]. The authors continue to state that the rate
Lung decortication was done, there were alveolar perforations, large one of complications was higher if the procedure was done under urgent or
was repaired. Irrigation of the cavity was done with warm normal saline. emergent conditions especially in the emergency unit [9]. This is evident
UWSD kept in situ for drainage (air bubbles come out with pressure and from our series as 2 out of 4 cases were emergency, nonetheless such
minimal blood) and the chest wound closed in layers. She faired well in morbidity is preventable if proper training is offered and standard care
the wards for 10 days with chest physiotherapy, intravenous antibiotics and operating procedures are adhered regardless of the setting. Control
and adequate analgesia. Thereafter she was discharged and attended our plain chest X-ray can be done right after the procedure to confirm the
out-patient clinic for a follow up after 2 weeks with no complains, the placement of the chest-tube and to detect early any complications. This
thoracotomy wound had healed well and on respiratory examination, also includes timely patient follow up and reviewing the patient as a
the trachea was central and bilateral air entry in both lung fields was whole clinically; to check the patency of the underwater seal drain by its
noted on auscultation. oscillation, a complete chest examination and this can be aided by a
bedside chest ultrasonography. Ultrasonography can be done bedside in
3. Discussion resource-limited settings like ours, poses no radiation risks, and can
guide clinicians on the retained effusions.
Chest tube thoracostomies are among the most common invasive Tube malposition is also a common morbidity and it is more common

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J. Lodhia et al. International Journal of Surgery Case Reports 108 (2023) 108416

if placed in suboptimal and under emergent conditions and when used a Samwel Chugulu – Review medical records
trochar compared to blunt dissection technique. CT-scan can best define Kondo Chilonga – Editing of script
the malposition as seen in cases 3 and 4, compared to plain chest X-rays David Msuya – Clinical supervisor and editing of script
[10,11]. Chest tubes can be malpositioned into lung parenchyma, lung
fissure or mediastinum, especially in pre-existing pleural conditions like Guarantor
adhesions. They can cause damage to pulmonary vessels and cause
inadequate drainage hence should repositioned or replaced to improve Jay Lodhia.
outcome [10]. Tubes inserted far deep can reach the mediastinum and
can injure the pericardium, esophagus and/or major blood vessels. This Research registration number
was evident in case 2 where no major structures were injured and the
tube was successfully revised intra-operatively. Risk of intra-abdominal N/A.
tube malposition can be seen if tubes are inserted below the “safety
triangle” and poses risk to injure hollow and solid abdominal organs Provenance and peer review
[10]. Other potential causes of intra-abdominal chest tube malposition
include late pregnancy, intra-abdominal tumors, ascites, obesity or even Not commissioned, externally peer-reviewed.
full expiration [12]. In case 1 the tube perforated the left hemi­
diaphragm but luckily did not injure any peritoneal organs hence was
managed conservatively after removing the chest tube. Declaration of competing interest
There are numerous ways to prevent complications as elicited by
Kerger et al. Trochar can be avoided, smaller-bore tubes can be used by The authors declare they have no competing interests.
Seldinger-technique and with the use of a dilator. The authors continue
to add the use to blunt-dissection with digital palpation of the pleura can Acknowledgement
be sought when using larger bore tubes, however in general smaller
tubes should be preferred when possible [13]. A thoracoscope can also The authors would like to thank the patient and her son for
be used if the setting allows however in a resource-limited setting like permission to share her medical history for educational purposes and
ours this was not feasible. Clinicians should also aim to insert the chest publication.
tubes through the “safety triangle” in order to avoid injuries to the breast
tissue, internal mammary artery and external thoracic muscles [13]. References

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