Thoracostomy

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Thoracostomy
PMC3395864 1757-7241-20-10-1.png
A tube thoracostomy unit
Specialty Pulmonology
ICD-10-PCS Z46.82
MeSH D006468
MedlinePlus 002947
eMedicine 80678

A thoracostomy is a small incision of the chest wall, with maintenance of the opening for drainage. [1] It is most commonly used for the treatment of a pneumothorax. This is performed by physicians, emergency response nurses, and paramedics, usually via needle thoracostomy or with a thoracostomy tube (chest tube).

Thoracic wall

The thoracic wall or chest wall is the boundary of the thoracic cavity.

In medicine, drainage refers to the removal of fluids and/or gases from a body part.

Pneumothorax Abnormal collection of air in the pleural space that causes an uncoupling of the lung from the chest wall

A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases the amount of air in the chest increases when a one-way valve is formed by an area of damaged tissue, leading to a tension pneumothorax. This condition can cause a steadily worsening oxygen shortage and low blood pressure. Unless reversed by effective treatment this can be fatal. Very rarely both lungs may be affected by a pneumothorax. It is often called a collapsed lung, although that term may also refer to atelectasis.

Contents

A thoracostomy is often confused with thoracotomy, which is a larger incision commonly used to gain access to organs within the chest.

Thoracotomy incision into the pleural space of the chest

A thoracotomy is a surgical procedure to gain access into the pleural space of the chest. It is performed by surgeons to gain access to the thoracic organs, most commonly the heart, the lungs, or the esophagus, or for access to the thoracic aorta or the anterior spine. The purpose of a thoracotomy is the first step used to facilitate thoracic surgeries including lobectomy or pneumonectomy for lung cancer or to gain thoracic access in major trauma.

Medical uses

When air, blood, or other fluids accumulate in the pleural cavity it may be drained by thoracostomy. Whereas air in this space (pneumothorax) may be released by needle thoracostomy, other substances require drainage with a thoracostomy tube. [2]

Pleural cavity thin fluid-filled space between the two pulmonary pleurae (visceral and parietal) of each lung

The pleural cavity also known as the pleural space, is the thin fluid-filled space between the two pulmonary pleurae of each lung. A pleura is a serous membrane which folds back onto itself to form a two-layered membranous pleural sac. The outer pleura is attached to the chest wall, but is separated from it by the endothoracic fascia. The inner pleura covers the lungs and adjoining structures, including blood vessels, bronchi and nerves. The pleural cavity can be viewed as a potential space because the two pleurae adhere to each other under all normal conditions. Parietal pleura projects up to 2.5 cm above the junction of the middle and medial third of the clavicle

Contra-indications

There are no absolute contraindications to thoracostomy. There are relative contraindications (such as coagulopathies); however, in an emergency setting these are outweighed by the necessity to re-inflate a collapsed lung by draining fluid/air from the space around the lung. [2]

Coagulopathy is a condition in which the blood’s ability to coagulate is impaired. This condition can cause a tendency toward prolonged or excessive bleeding, which may occur spontaneously or following an injury or medical and dental procedures. Of note, coagulopathies are sometimes erroneously referred to as "clotting disorders"; a clotting disorder is a predisposition to clot formation (thrombus), also known as a hypercoagulable state or thrombophilia.

Technique

Drainage of the pleural cavity is achieved by the surgeon making a primary incision in the skin followed by a second incision through the muscle between the ribs. This way a tube may be guided into the chest to allow for drainage. Chest tubes are designed to collect this drainage and prevent anything from leaking back into the pleural space. This is accomplished by a check valve, usually part of a specialized drainage system with an underwater seal. Depending on the amount of air/fluid to be drained, the collection bottle may need to be periodically changed. [2]

Check valve valve that allows fluid to flow through it in only one direction

A check valve, clack valve, non-return valve, reflux valve, retention valve or one-way valve is a valve that normally allows fluid to flow through it in only one direction.

Risks/complications

Rare complications are mostly due to placement technique, inexperience of the interventionist, and emergent vs. elective circumstances. The most common complications are recurrent pneumothorax (incomplete recovery, but an expected course), infection, and organ injury (due to mechanical damage). [3]

Esophageal injury is rare. If saliva and chyme contents drain from the chest tube, that should raise suspicion of esophageal injury. The main treatment of esophageal injury is surgical repair. The stomach is also rarely injured. Proper technique and not using a trocar during the procedure decreases the risk of this from occurring. [3]

See also

Related Research Articles

Pleurisy pleural disease that is characterized by swelling, due to inflammation of the pleura, the lining of the pleural cavity surrounding the lung or lungs.

Pleurisy, also known as pleuritis, is inflammation of the membranes that surround the lungs and line the chest cavity (pleurae). This can result in a sharp chest pain while breathing. Occasionally the pain may be a constant dull ache. Other symptoms may include shortness of breath, cough, fever or weight loss, depending on the underlying cause.

Pleural effusion accumulation of excess fluid in the pleural cavity

A pleural effusion is excess fluid that accumulates in the pleural cavity, the fluid-filled space that surrounds the lungs. This excess fluid can impair breathing by limiting the expansion of the lungs. Various kinds of pleural effusion, depending on the nature of the fluid and what caused its entry into the pleural space, are hydrothorax, hemothorax (blood), urinothorax (urine), chylothorax (chyle), or pyothorax (pus) commonly known as pleural empyema. In contrast, a pneumothorax is the accumulation of air in the pleural space, and is commonly called a "collapsed lung".

Pleurodesis

Pleurodesis is a medical procedure in which the pleural space is artificially obliterated. It involves the adhesion of the two pleurae.

Chest tube

A chest tube is a flexible plastic tube that is inserted through the chest wall and into the pleural space or mediastinum. It is used to remove air (pneumothorax), fluid, or pus (empyema) from the intrathoracic space. It is also known as a Bülau drain or an intercostal catheter.

Hemothorax Blood accumulation in the pleural cavity

A hemothorax is an accumulation of blood within the pleural cavity. The symptoms of a hemothorax include chest pain and difficulty breathing, while the clinical signs include reduced breath sounds on the affected side and a rapid heart rate. Hemothoraces are usually caused by an injury but may occur spontaneously: due to cancer invading the pleural cavity, as a result of a blood clotting disorder, as an unusual manifestation of endometriosis, in response to a collapsed lung, or rarely in association with other conditions.

Hydrothorax pleural effusion containing serous liquid

Hydrothorax is a type of pleural effusion in which transudate accumulates in the pleural cavity. This condition is most likely to develop secondary to congestive heart failure, following an increase in hydrostatic pressure within the lungs. More rarely, hydrothorax can develop in 10% of patients with ascites which is called hepatic hydrothorax. It is often difficult to manage in end-stage liver failure and often fails to respond to therapy.

Chylothorax type of pleural effusion

A chylothorax is an accumulation of lymphatic fluid in the space surrounding the lung. Lymph formed in the digestive system is called chyle and accumulates in the pleural space due to either disruption or obstruction of the thoracic duct. In people on a normal diet, this fluid collection can sometimes be identified by its turbid, milky white appearance, since chyle contains triglycerides. It is important to distinguish a chylothorax from a pseudochylothorax, which has a similar appearance, but is caused by more chronic inflammatory processes, and requires a different treatment.

Thoracentesis medical procedure

Thoracentesis, also known as thoracocentesis or pleural tap, is an invasive procedure to remove fluid or air from the pleural space for diagnostic or therapeutic purposes. A cannula, or hollow needle, is carefully introduced into the thorax, generally after administration of local anesthesia. The procedure was first performed by Morrill Wyman in 1850 and then described by Henry Ingersoll Bowditch in 1852.

Respiratory disease disease of the respiratory system

Respiratory disease, or lung disease, is a medical term that encompasses pathological conditions affecting the organs and tissues that make gas exchange difficult in air-breathing animals. They include conditions of the respiratory tract including the trachea, bronchi, bronchioles, alveoli, pleurae, pleural cavity, and the nerves and muscles of respiration. Respiratory diseases range from mild and self-limiting, such as the common cold, to life-threatening diseases such as bacterial pneumonia, pulmonary embolism, acute asthma and lung cancer.

Hemopneumothorax, or haemopneumothorax is the condition of having air in the chest cavity (pneumothorax) and blood in the chest cavity (hemothorax). A hemothorax, pneumothorax, or the combination of both can occur due to an injury to the lung or chest.

Lobectomy of the lung is a surgical operation where a lobe of the lung is removed. It is done to remove a portion of diseased lung, such as early stage lung cancer.

Pulmonary laceration chest injury in which lung tissue is torn or cut

A pulmonary laceration is a chest injury in which lung tissue is torn or cut. An injury that is potentially more serious than pulmonary contusion, pulmonary laceration involves disruption of the architecture of the lung, while pulmonary contusion does not. Pulmonary laceration is commonly caused by penetrating trauma but may also result from forces involved in blunt trauma such as shear stress. A cavity filled with blood, air, or both can form. The injury is diagnosed when collections of air or fluid are found on a CT scan of the chest. Surgery may be required to stitch the laceration, to drain blood, or even to remove injured parts of the lung. The injury commonly heals quickly with few problems if it is given proper treatment; however it may be associated with scarring of the lung or other complications.

Subcutaneous emphysema Surgical Emphysema

Subcutaneous emphysema is when gas or air is in the layer under the skin. Subcutaneous refers to the tissue beneath the skin, and emphysema refers to trapped air. Since the air generally comes from the chest cavity, subcutaneous emphysema usually occurs on the chest, neck and face, where it is able to travel from the chest cavity along the fascia. Subcutaneous emphysema has a characteristic crackling feel to the touch, a sensation that has been described as similar to touching Rice Krispies; this sensation of air under the skin is known as subcutaneous crepitation.

Plural disease occurs in the pleural space, which is the thin fluid-filled area in between the two pulmonary pleurae in the human body, there are several disorders that can occur

Resuscitative thoracotomy thoracotomy performed to resuscitate a major trauma patient in cardiac arrest

A resuscitative thoracotomy is a thoracotomy performed to resuscitate a major trauma patient who has sustained severe thoracic or abdominal trauma and who has entered cardiac arrest because of this. The procedure allows immediate direct access to the thoracic cavity, permitting rescuers to control hemorrhage, relieve cardiac tamponade, repair or control major injuries to the heart, lungs or thoracic vasculature, and perform direct cardiac massage or defibrillation. For most persons with thoracic trauma the procedure is not necessary; only 15% of those with thoracic injury require the procedure.

Tracheal deviation

Tracheal deviation is a clinical sign that results from unequal intrathoracic pressure within the chest cavity. It is most commonly associated with traumatic pneumothorax, but can be caused by a number of both acute and chronic health issues, such as pneumonectomy, atelectasis, pleural effusion, fibrothorax, or some cancers and certain lymphomas associated with the mediastinal lymph nodes.

Eloesser flap

The Eloesser flap is a surgical procedure developed by Dr. Leo Eloesser in 1935 at the San Francisco General Hospital. It was originally intended to aid with drainage of tuberculous empyemas, since at the time there were no effective medications to treat tuberculosis. The procedure was used extensively until the development of effective chemotherapy for tuberculosis in the late 1940s and early 1950s. It is still used occasionally for chronic empyemas.

References

  1. Dorland, W. A. Newman (2009). Dorland's pocket medical dictionary (28th ed.). Philadelphia, PA: Saunders/Elsevier. ISBN   978-1-4160-3420-9.
  2. 1 2 3 Nicks, Bret A.; Manthey, David (2011). Pneumothorax. Tintinalli's Emergency Medicine. New York City: McGraw-Hill.
  3. 1 2 Kwiatt, Michael; Tarbox, Abigail; Seamon, Mark J.; Swaroop, Mamta; Cipolla, James; Allen, Charles; Hallenbeck, Stacinoel; Davido, H. Tracy; Lindsey, David E. (2014). "Thoracostomy tubes: A comprehensive review of complications and related topics". International Journal of Critical Illness and Injury Science. 4 (2): 143–155. doi:10.4103/2229-5151.134182. ISSN   2229-5151. PMC   4093965 . PMID   25024942.