Thoracotomy tube placement and management: What every pediatric anesthesiologist should know

Myron Yaster MD, Shawn Jackson MD PhD, Ethan Sanford MD, and Justin L. Lockman MD MSEd

The November 19, 2024 PAAD: External ventricular drains: What the pediatric anesthesiologist should know (https://ronlitman.substack.com/publish/posts/detail/151509633?referrer=%2Fpublish%2Fposts ) evoked a large reader response asking for a similar PAAD on the management of thoracostomy tubes. Initially I thought, “Chest tubes have been around for centuries…what could be new about this?” Then, I found this article by Drouin et al.¹ published in the November 2024 issue of the Lancet Respiratory Medicine. It turns out there are a few new things! Myron Yaster MD

Original article

Drouin E, Wiel E, Lansiaux E, Duffin J, Chambellan A. Thoracentesis: an old story and some new sources. Lancet Respir Med. 2024 Nov 13:S2213-2600(24)00342-4. doi: 10.1016/S2213-2600(24)00342-4. Epub ahead of print. PMID: 39549710.

Ever since ancient times, it has been well known that the optimal treatment of an abscess is drainage. “Hippocrates (460–377) recommended the evacuation of pleural fluid through an incision “down to the bone at the third lowest rib, then pierce right through to the inside with a straight pointed trephine, and after boring, draw off a little fluid. In the 13th century, the technique of thoracic drainage through a wooden tube was described by the learned poet Wolfram von Eschenbach (1170–1220). The growing use of gunpowder during the 1500s generated more occasions for wounds complicated by pneumothorax, pleural effusions, and empyema.”¹

“Until the advent of percussion and auscultation, the exact location of an effusion was a matter of conjecture, making the operation exceedingly risky.”¹ Drouin et al. recently discovered two 18^th century manuscripts that discuss where thoracentesis should be performed (anterior or posterior) and at which intercostal space. Should the ribs be counted from the bottom to top (the old way) or top to bottom (the modern way)? It’s an interesting read for those interested in medical history.

In 2025, we no longer rely on percussion and auscultation alone to locate effusions and place thoracostomy tubes. We now have chest radiography and ultrasound to visualize not only location but also size and consistency of fluid collections, allowing risk reduction before we even start. We also have the benefit of modern Pleur-evac systems, which consolidate the ‘3 chambers’ into a single, easy-to-use, portable unit to simplify management.

When placing a thoracostomy tube remember to place the ipsilateral arm above the head and the needle or Kelly clamp is placed over the top of the rib (not below it) to avoid the neurovascular bundle. Typically, the tube is placed in the anterior axillary or mid-axillary line at either the 4^th or 5^th intercostal space. However, it is common these days to use ultrasound to aid with diaphragm identification, gauge the size of the effusion (when present) and the relative location of the lung to avoid iatrogenic lung injury and resultant air leak. Ultrasound technique may obviate the classic anatomic landmark techniques, though anatomic technique is well established, relatively safe, and likely more rapidly deployed in emergent situations such as tension pneumothorax. Ultrasound may also allow direction of the tube inferiorly or superiorly (for fluid or air, respectively), though this is admittedly an imperfect practice.

But how to manage a chest tube and drain once inserted? A fantastic resource that our SPA colleague Dr. Dabe Chatterjee referred us to is Dr. Nick Mark’s ICU OnePager which provides critical care education one page at a time. It is simple, free, and open source (https://onepagericu.com/#google_vignette).²

All you need to know about what to do with the chest tube is depicted in this wonderful figure from Dr. Nick Mark’s ICU OnePager “Assessment of Chest Drains”.² This figure “shows you how they work and demonstrates a 5-step tool for assessing positioning, drainage, tidaling, air leak, and suction.” In a child with existent preop chest tube, noting these functions is important so that changes during the anesthetic can be appropriately addressed. It also demonstrates how the old fashioned three-bottle drainage system works and how modern chest drains consolidate these chambers in to a single unit. (Side note From Myron: I actually had to use this knowledge to build a water-seal chamber on a flight from Israel back to the USA about 25 years ago. It was a wild ride in which I resuscitated a patient mid-flight. My initial attempts at CPR and defibrillation failed and in desperation, as I went thru my mental list of the 5 Hs and Ts [since there was no pedi-crisis app yet], as a last-ditch effort I placed a 20g catheter in the 2^nd intercostal space at the midclavicular line. The needle produced an immediate “whoosh,” followed by return of cardiac function. I “MacGyvered” the catheter to IV tubing and placed the free end into a half-filled bottle of water, thus making the open pneumothorax into a closed one. The plane landed emergently and the man survived to be evacuated from the airplane.)

Finally, for tension pneumothorax, needle decompression is performed at either the 2^nd intercostal space midclavicular line (the historical way, still preferred in children) or the now preferred insertion site for adults and perhaps larger children, the 4^th or 5^th intercostal space just anterior to the mid axillary line.³ The 2nd intercostal space midclavicular line is still preferred in obese or overweight patients due to the relative paucity of fat at that location.³

Send your thoughts and comments to Myron at myasterster@gmail.com who will post in a Friday Reader Response.

References

1. Drouin E, Wiel E, Lansiaux E, Duffin J, Chambellan A. Thoracentesis: an old story and some new sources. Lancet Respir Med 2024 (In eng). DOI: 10.1016/s2213-2600(24)00342-4.

2. Mark N. Assessment of chest drains. (https://onepagericu.com/chest-tubes#google_vignette).

3. Azizi N, Ter Avest E, Hoek AE, et al. Optimal anatomical location for needle chest decompression for tension pneumothorax: A multicenter prospective cohort study. Injury 2020 (In eng). DOI: 10.1016/j.injury.2020.10.068.