Chest Tube Complications

Author: Shane Solger, MD & Andrea Greene, MD, MPH

Reviewed by Leon Boudourakis, MD

 

Deciding is easy.  An obese patient with a flail chest needs a chest tube. You “gown up”, create your sterile field, position the patient, make the cut…blood seeps out and doubt rushes in. What if bright red blood comes back? What if it’s milky? What if nothing comes out? What if you penetrate the pericardium?

The concept is simple: poke into the chest and suck out all the bad stuff. While we love our ultrasound devices, the chest tube is one of the truly “hands-on”, old-school procedures within our purview. Drop the probe. You need physical landmarks and your trusty old index finger. Recall the infamous “triangle of safety” shaped anteriorly by the lateral border of the pectoralis major, posteriorly by the lateral border of the latissimus dorsi, and inferiorly by the superior border of the 5th intercostal rib. But don’t be fooled, staying inside the triangle doesn’t eliminate the risk of harm to your patient. The triangle of safety is not “safe” at all if you don’t know what you’re doing. Chest tube insertion can be fraught with complications, and one of our responsibilities in the ED and ICU is to troubleshoot a chest tube gone awry.

Whether you are placing the tube yourself or taking care of a patient with a chest tube, you need to know what can go wrong and how to fix it. Next, in order from least scary to most-dreaded, we present the complications, diagnostics, and management for common and uncommon complications of tube thoracostomy.

Intrafissural Placement

What happened?

The tube is in between the lobes of the lung.

What patients are at risk?

Patients who undergo far lateral tube placement, whether accidental or to avoid traumatic or anatomical obstacles (i.e. rib fractures)

Complications: 

The drainage ports may become occluded or the chest tube may eventually erode into surrounding lung tissue. Poor drainage may lead to an infection. In the literature, the true danger hasn’t borne itself out yet. For those with isolated primary spontaneous pneumothorax, a fissural placement is more likely than a pleural chest tube to require another tube but has not been found to cause a difference in side effects or length of hospital stay.[13] In the trauma literature, intrafissural placement has not been found to change the amount or duration of drainage.[14]

What do we do?

It depends. Intrafissural placement is not a contraindication to use the chest tube. Consider leaving it in place if it’s doing its intended job and closely monitor the patient. If it’s not working, reposition or replace it.

The Obstructed Drain

What happened?

Something is blocking chest tube drainage. Could be a kinked tube, obstruction (clot or debris), or intraparenchymal placement.

What patients are at risk?

Anyone.

Complications:

You will have undrained and non-resolving pleural collections or air/fluid. Your intervention chest tube placement failed. So you have the same problem you started with, but now you have to fix it fast before tension physiology sets in.

What do we do?

Confirm your suspicion: Set it to water seal. In an unobstructed tube, if you had previously been able to drain a pleural effusion and it is still in the tubing, the fluid should fluctuate with breathing or coughing; absence would indicate something is wrong. Consider a CT if the tube is in a good position but functioning poorly. You can irrigate the tube with saline to clear out debris or insert a Fogarty embolectomy catheter through the tube, inflating distal to the potential obstruction, and pulling it back out of the tube. An unused chest tube can be used as a reference to estimate the distance needed to advance the Fogarty catheter. Avoid “milking” the tube, as this can cause transient large negative pressures that may be dangerous for the patient. The tube may need to be replaced with a larger-sized one if the fluid is viscous (i.e. empyema). If the tube is kinked, simply unkink it.

Unexpected Air Leak

What happened?

We anticipate air leaks on the initial insertion of the tube into a pneumothorax. New air leaks may be due to a new pneumothorax or bronchopulmonary fistula.

What do we do?

Look at the insertion site to make sure the tube is all the way in. Ensure that it is properly secured/sutured to create a tight seal. When all else fails, get a CXR, and manage the issue based on the etiology.

Draining Milky Fluid

What happened?

Your tube tapped into purulent fluid (empyema), a thoracic duct (chylothorax), or a cholesterol effusion (pseudochylothorax). Right-sided chylothorax happens with injuries below the 5th vertebra, while left-sided chylothorax occurs if the injury is above the 5th vertebra.

What patients are at risk?

This depends on what is causing the fluid to accumulate. Empyemas are associated with infection. Aside from trauma, lymphoma may cause a chylothorax, and those with tuberculosis or rheumatoid arthritis might develop a pseudochylothorax.

What do we do?

Call your cardiothoracic surgeons if you’re worried about intraparenchymal laceration. If the etiology is uncertain, add triglycerides to the fluid analysis cell count, protein, adenosine deaminase, culture, and LDH.

Subcutaneous Placement

What happened?

All or some of the chest tube ports are in the fat, skin, or muscle.

What patients are at risk?

Patients with characteristics causing inadequate identification of physical landmarks (obesity, chest wall hematomas, multiple rib factors, or crashing patients requiring rapid insertion).

Complications:

Subcutaneous emphysema (see next complication) can cause discomfort, anxiety, pacemaker dysfunction, or upper airway obstruction.

What do we do?

Hide your head in the sand or lament over your insufficient blunt dissection. If the distal drain is inside the pleural space, and the proximal drain is in the tissue, then simply advance the tube until they are both in the pleural space (this needs to be done while sterile). If the whole tube is in the subcutaneous tissue, replace it with a new one.

Subcutaneous Emphysema

What happened?

Air is in the subcutaneous tissue either from subcutaneous placement, improperly placed tube, or an unfortunate consequence of a properly placed chest tube; air will try to get out of the pleural space, and if the tube is obstructed, it could leak through the skin.

What patients are at risk?

Those same folks with a subcutaneous placement, but kinked, clamped, or clogged tubes can also cause it. Stagnant fluid in the dependent portions of the chest tube can obstruct if the pleurovac is set to seal.

Complications:

Same as above.

What do we do?

Subcutaneous emphysema can be benign and resorb over time. If there is subcutaneous emphysema and nothing draining from the tube, evaluate the tube and collecting system for a cause for blockage, consider a chest X-ray (CXR) to check for kinking, and turn the Pleurovac to suction to try to clear the tube.

Re-Expansion Pulmonary Edema (REPE)

What happened?

The exact pathophysiology is unknown. The vague answer is that fluid shifts are occurring across the capillary-alveolar membranes. Risk is higher when re-expansion occurs rapidly.

What patients are at risk?

Younger patients (<40 years old), prolonged pneumothorax (~3 days), greater initial lung collapse (>30% lung collapse), too much initial suction, or >1L rapidly removed after chest tube insertion.

Complications:

Death – the mortality rate is 20%. The incidence in humans is around 1%. A rhesus monkey study showed that monkeys with a) pneumothorax ongoing for >3 days and b) pneumothorax resolved quickly with suction at a pressure of -10 cm H2O had a 100% incidence of REPE, while 0% of those set to water seal or who had their lung re-expanded within an hour of the pneumothorax while on suction went on to develop REPE. A similar study involving goats also found that REPE developed exclusively in those animals with a) pneumothorax ongoing for 72 hours and b) re-expansion with suction.

What do we do?

Treat it like ARDS. Clinical Picture: a young patient gets a chest tube, pneumothorax rapidly resolves, then he starts coughing uncontrollably and the respiratory status deteriorates. If you’re uncertain if it’s REPE, get a CXR to ensure good positioning and integrity of the tube. With a high suspicion of REPE, clamp the tube, put the pleurovac to underwater seal, and provide supportive care. You can place the patient in lateral decubitus with the affected side facing up. They may need non-invasive positive pressure or mechanical ventilation.

Abutment of the mediastinum

What happened?

A chest tube entering the chest, especially on the left side, is close to the heart, esophagus, and trachea. Normal respiratory variations may force the tube into the mediastinal structures, and there have been reports of injury or interference with mediastinal structures and cardiac function.

What patients are at risk?

Patients with thoracic deformities (i.e. scoliosis) or enlarged hearts

Complications:

There may be variable hemodynamic effects based on what the tube is touching. Cardiac dysrhythmia from stimulation of the heart, pericardium, or vagus nerve by the tube has been reported.

What do we do?

Retract the tube a few centimeters – if the dysrhythmia was related to the tube abutting the heart, it usually resolves quickly.

Phrenic Nerve Palsy

What happened?

The chest tube compressed the phrenic nerve near the mediastinum. Diaphragmatic paralysis might present as an elevated hemidiaphragm on CXR.

What patients are at risk? 

Neonates and those whose tube is placed close to the spine.

Complications:

Prolonged ventilator use and the trouble that comes with it.

What do we do?

This can be reversible with conservative care. Pull the tube back a few centimeters. If it doesn’t resolve, call your surgeons.

Horner’s Syndrome

What happened?

The chest tube is too high up in the apex, usually above the 3rd posterior rib. This can compress the sympathetic ganglion via direct pressure, local inflammation, or a hematoma, causing Horner’s Syndrome (miosis, proptosis, anhidrosis, enophthalmos).

What patients are at risk?

Anyone requiring a chest tube.

What do we do?

Pull the chest tube back 2-3 cm, and confirm placement with a CT. Most patients will fully recover.

Iatrogenic Hemothorax

What happened?

A lot of blood came out of the tube. Causes include tube placement underneath the ribs and subsequent intercostal artery injury or mediastinal impingement. ATLS tells you to go to the OR when the amount of evacuated blood is more than 1.5 liters are returned immediately after chest tube insertion or greater than 200 cc/hr. Look for pulsatile bleeding, clotting, a pleural fluid hematocrit >½ of serum hematocrit.

What patients are at risk?

The elderly as their blood vessels become more tortuous over time

Complications:

Hemorrhagic shock

What do we do?

Call your cardiothoracic surgeons. If you lacerated an intercostal artery, you can consider replacing the tube with a 24 Fr foley catheter with a 30 cc balloon and apply one pound of tension to tamponade the bleeding.

Intrapulmonary/parenchymal placement

What happened?

You stabbed the lung. Maybe you weren’t quite as thorough with your finger sweeps to clear adherent lung tissue. Be suspicious if nothing is draining from the tube, and acute onset hemoptysis will be a less subtle clue.

What patients are at risk?

Prior surgery or pleural inflammation might cause the lung to adhere to the thoracic wall.

Complications

Severe bleeding, respiratory failure, ineffective chest tube, creation of a bronchopleural fistula

What do we do?

You may have to initiate mechanical ventilation, resuscitation with blood products, blood pressure support, and preparation for emergent thoracotomy. If the patient is stable and the pneumothorax didn’t resolve, the chest tube may have all of its drainage ports in the lung parenchyma. You can retract the tube a few centimeters so that at least one is in the pleural space to allow it to decompress the lung, and then the tube will need to be replaced. Obtain a 2-view CXR (if possible), but there’s a chance it may be missed; CT may be required to make the diagnosis.

Intra-abdominal/Transdiaphragmatic Placement

What happened?

You’re in the abdomen. Have a high suspicion if your chest tube begins to drain bile, blood, or gastric contents.

What patients are at risk?

Those with intra-abdominal tumors, ascites, obesity, late pregnancy, paralyzed diaphragms, gastric or intestinal diaphragmatic herniation (bowel may look like a pneumothorax), or an unlucky patient who received tube placement below the 5th intercostal space.

Complications:

Damage to the visceral organs

What do we do?

Ensure large-bore IV access, prepare RBCs, call the trauma surgeons, and send pre-op labs. Obtain a CT to assess the extent of the injury. If the diaphragm is the only injured organ, place a chest tube higher (but stay in the safe triangle).

Intracardiac placement

What happened?

This is the big one. The most dreaded complication. A real heartstring-tugging, pit-in-your-stomach, please-don’t-let-this-happen-to-me moment. Be fearful, stay woke.

What patients are at risk?

Patients with a big heart. Not a SWEETheart but a BIG heart (cardiomegaly).

What do we do?

Check pulses. The patient’s pulses first, then check your pulse. Then call surgery STAT.

Pearls and Pitfalls:

1. 1. Anticipate a difficult tube based on patient risk factors (i.e. obesity, trauma).
2. 2. To minimize muscle interference and difficulties associated with tissue dissection, insert the tube in the triangular zone. 
3. 3. Use your finger! While ultrasonography can help confirm that landmarks are leading you to the right spot, tactile information is key to know where you are, check for scar tissue, and help guide your tube.
4. 4. Confirm placement with CXR, but get the CT if you’re not sure what’s wrong with the tube.
5. 5. Obtain surgical consultation if you suspect a complication or anticipate difficult placement.

 

Quick Reference:

Problem	Solution
Subcutaneous placement Intrafissural placement Unexpected air leak Blocked tube/drain	Replace tube
Kinked tube Intrapulmonary/parenchymal placement Abutment of mediastinum Horner’s Syndrome Phrenic nerve palsy	Pull Back 2-3 cm, check hemodynamics, consult surgery if concern for hemorrhage
Intracardiac placement Abutment of mediastinum Hemothorax Intra-abdominal/Transdiaphragmatic Draining milky fluid (unexpected) Failure of the lung to re-expand	Stabilize, resuscitate, consult surgery
Intrafissural placement Re-Expansion Pulmonary Edema Draining milky fluid (expected) Persistent air leak (expected initially with the aspiration of pneumothorax)	Leave the current tube in place

References

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