|Year : 2018 | Volume
| Issue : 4 | Page : 166-170
Thoracostomy tube in trauma surgery: Does position really matter?
Jerry G Makama1, Nuhu Yusuf1, Sunday Edaigbini2, Eyo E Ekpe3
1 Department of Surgery, Barau Dikko Teaching Hospital and Kaduna State University, Kaduna, Nigeria
2 Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
3 Department of Surgery, University of Uyo Teaching Hospital, Uyo, Nigeria
|Date of Submission||25-Apr-2019|
|Date of Acceptance||26-Nov-2019|
|Date of Web Publication||10-Feb-2020|
Dr. Jerry G Makama
Department of Surgery, Barau Dikko Teaching Hospital and Kaduna State University, Kaduna
Source of Support: None, Conflict of Interest: None
Background: In chest trauma, the conditions that compromise breathing very fast include hemothorax (HTx), pneumothorax (PTx), or both (HPTx). Fortunately, these conditions can be managed with tube thoracostomy (TT). This study was performed to determine whether TT position affects the rate of secondary intervention.
Patients and Method: We studied adult trauma patients who underwent TT placement over a period of one year (from March 2017 to March 2018) in 3 Nigerian teaching hospitals. Classification of tube placement by radiologist was considered as ideal when the tube was apically directed and placed in the pleural cavity. Non-ideal TT was defined within the fissure or supradiaphragmatic position. The primary outcome was defined as TT replacement, additional TT tube insertion, or surgical intervention.
Results: Ninety seven chest trauma patients who underwent TT placement. Indications for placement were HPTx (43.2%), HTx (26.8%), and PTx (30.0%). Majority of patients were male (66%), median age of 40.8 years (IQR 16–55 years), and blunt (71.1%) trauma. Ideal TT positioning was found in 76 (78.4%) and non-ideal 21 (21.6%). Secondary intervention rate was 4 (19.0%) including 3 (14.25%) replaced TT and 1 (4.75%) thoracotomy. Rate of secondary intervention for ideal and non-ideal TT position was 1 (1.0%) and 19.0% (P = 0.009), respectively. The difference in rate of secondary intervention was not significant (25.1% vs 34.1%, P = 0.09).
Conclusion: Position of a non-kinked TT with the sentinel hole within the thoracic cavity does not affect secondary intervention rates. Given over 20% of individuals with additional TT placement required operative intervention for definitive management, early operative intervention in the setting of non-kinked TT provides ideal patient care.
Keywords: Chest trauma, chest tube malposition, thoracostomy tube
|How to cite this article:|
Makama JG, Yusuf N, Edaigbini S, Ekpe EE. Thoracostomy tube in trauma surgery: Does position really matter?. Arch Int Surg 2018;8:166-70
| Introduction|| |
The management of hemothorax (HTx), pneumothorax (PTx), or both (HPTx) in the majority of trauma patients with chest injury, particularly in the acute phase has been essentially, the insertion of chest tube popularly known as tube thoracostomy (TT).,, The tube is often inserted into the pleural cavity so as to drain the fluid be it liquid or air. This intervention has been proven to quickly restore free expansile movement of the lungs of patients who have sustained chest trauma, thereby enhancing ventilation of the lungs in the affected side., The chest tube is commonly inserted through the chest wall at the level of the 5th intercostal space anterior to mid-axillary line. The reasons for this position has been adjudged to be due to safety and second an attempt to achieve maximum functional level of the tube. Similarly, the intrathoracic placement of the tube has been adjudged to be important for the tube to be efficient and deliver the desired outcome. The norm has been an apical placement of the tube within the pleural cavity so that the air or particularly the liquid is drained by the help of both gravity and siphon mechanism. The tube in this position is often described an “ideal TT” by radiologist as having being placed properly. The TT tube that is placed in a position outside this such as locating it immediately above the diaphragm (supradiaphragmatic level) or in the lung fissure is considered “non-ideal TT” and/or improperly placed. The incidence of improperly placed TT has been noted to be rising and is currently being quoted to be 30%., The management of improperly placed TT has been to observe, repositioning the tube, tube replacement, additional TT placement, or early surgical intervention (thoracotomy). These secondary interventions, as it is already known, do not often go without sequelae. Therefore, the aim of this study is to determine whether intrathoracic placement of TT affects the rate of secondary intervention of chest tube insertion.
| Patients and Methods|| |
This was a 1-year prospective study conducted from March 2017 to March 2018 among trauma victims who presented in three major teaching hospitals of Nigeria. The teaching hospitals included Ahmadu Bello University Teaching Hospital, Zaria; Barau Dikko Teaching Hospital, Kaduna; and University of Uyo Teaching Hospital, Uyo. The research design consisted the use of proforma to collect the desired information among these trauma victims seen in the study areas over the study period.
Accident and Emergency Department (AED) of Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, is strategically located Northwestern region of Nigeria, along the way between Kano, a highly commercial city in the region and Kaduna, the capital city of Kaduna State, Nigeria. The traffic in the double lane highway that connects these two megacities is usually heavy associated with its attendant, extremely high rate of road traffic accidents. In addition, ABUTH serves as a referral as well as a teaching hospital for people living in Zaria municipal, which has a population of over 600,000 people. The hospital has a total capacity of 500 beds. Out of this number, 27 bed spaces are reserved for acute care in the Accident and Emergency Department which, currently, has been quoted to have high bed space occupancy rate of 0.8.
The Accident and Emergency Department (AED) of Barau Dikko Teaching Hospital-Kaduna State University (BDTH-KASU) is located at the center of Kaduna town, an old city that was the capital of the Northern region, Nigeria, with a current population of over 2 million people. The city has been a central commercial network of the entire northern region for long and fondly referred to as a mini Nigeria due to the composition of its population from different parts of the country as well as activities therein. The environment has a high rate of activities associated with attendant, extremely high rate of traffic accidents.
The Accident and Emergency Department of University of Uyo Teaching Hospital, Uyo
The Uyo Teaching hospital is one of the two tertiary health care institutions located in Uyo, the capital city of Akwa Ibom State. The state with a population of over 3,920,208 people is full of commercial activities in both land and water ways. The UUTH is a 400 bedded hospital and receives patients from the state as well as from the neighboring communities of Abia, Cross River and River States.
Hypothesis: In this study, our hypothesis was that the intrathoracic placement/position of the tube does not matter as long as the sentinel hole (proximal intrathoracic hole of the tube) is in the pleural cavity.
Intervention: All traumatic chest injury patients who presented with an indication for chest tube had TT, clinically monitored and managed until their symptoms were abated and subsequently discharged home.
Outcome measure: In this study, the intervention was tube thoracostomy. The primary outcome was secondary interventions such as repositioning TT, replacement of tube, additional TT placement, and early surgical intervention, while the secondary outcome was the clinical outcome of the patients such as improvement of symptoms or death.
Inclusion and exclusion criteria
Inclusion: All patients with diagnosed hemothorax, pneumothorax, or both, those who had chest tube insertion, and those in whom the sentinel hole was not outside the chest wall.
Exclusion: All chest trauma patients without HTx, PTx, or both; all patients with HTx, PTx, or both but did not have TT insertion (died before the attempt was made); and all patients with TT insertion but sentinel hole was outside the chest wall.
The information concerning the patient biodata, the type of chest injury sustained, the indication for chest tube insertion, the date of insertion, the category of doctor who placed the chest tube, reports of pre and post tube insertion chest X-ray, and the outcome of chest tube insertion were entered into a proforma. In addition, the information about secondary interventions, length of hospital stay, and outcome of management of those patients in whom their post chest tube insertion X-ray reports were considered non-ideal placement by the radiologists were obtained using the study proforma.
The data of a total of 97 patients who met the inclusion criteria were entered into a spreadsheet and analyzed using SPSS version 20.0 (SPSS Statistics, IBM Corporation, Armonk, New York) and results were presented in frequency tables, bar chart, and graphs. Level of statistical significance was set at P < 0.05.
The ethical committee of the various institutions approved the study. In addition, the permission of participants was obtained after a detailed explanation of the essence of the study, the risks involved including possible hemorrhage and injury to the lungs. Assurance was also given that the information derived from the study shall be used solely for the purpose of the research and will not be disclosed or given to a third party. In addition, they were also free to decline to participate or withdraw at any stage of the research.
| Results|| |
Ninety-Seven (97) chest trauma patients who underwent TT placement and met inclusion criteria were analyzed. The majority of patients were male (58.8%), median age of 40.8 years (IQR 16–55 years), and blunt trauma (71.1%) was the commonest form of injury [Table 1]. Indications for placement were HPTx (43.2%), HTx (26.8%), and PTx (30.0%). Ideal TT positioning was found in 76 (78.4%) with majority performed by senior residents, while non-ideal TT was in 21 (21.6%) hemithoraces with majority performed by junior residents [Table 2]. The ideal TT had only 1.0% that had secondary intervention, while the non-ideal TT had 4.1% that had secondary interventions [Table 3], which was not statistically (P = 0.49) significant. Of the 4.1% non-ideal TT that had secondary interventions, the majority (3.1%) constituted TT observation [Figure 1]. Of the 21 non-ideal TT, 100% (17 of 17) had no intervention and their outcome was good, while the 4 that had secondary interventions, 75% (3 of 4) of them had good outcome [Table 4]. The only case that had poor outcome in the non-ideal actually died due to diabetic Keto-acidosis, which was unrelated to trauma.
|Figure 1: Various secondary interventions for non-ideal tube thoracostomy|
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Majority of the patients who had thoracostomy tube placement performed by surgeon in-training had a hospital stay of 6–7 days with an average duration of 6.5 days, while the duration was 3–7 days (average 5.0 days) for thoracostomy tubes that were placed by a consultant.
| Discussion|| |
Drainage of the pleural cavity by means of tube thoracotomy is the commonest intervention in chest trauma and provides immediate relief of symptoms as well as definitive treatment in most cases.,,, In this study, the mortality was low 1.03% similar to the previous reports,, in many other parts of the world. Chest tube insertion is an essential skill that must be acquired by doctors like casualty officers, junior resident doctors, senior resident doctors, accident and emergency surgeon, trauma surgeons, and cardiothoracic surgeons. It is a relatively simple procedure that saves lives and can easily be acquired. In this study, it was not a surprise that the majority of the tube thoracostomies were done by senior resident doctors.
Indications for tube thoracostomy
In our environment, we found that the indications for TT were mainly pneumothorax, hemothorax, or both. These have remained common indications for TT among trauma patients in low and middle income countries.,, However, rare indications such as chylothorax, gastric/esophageal contents in the pleural space, rib fractures and positive pressure ventilations, penetrating chest injury, and traumatic arrests have been reported,, in high-income countries. Probably, these were possible due to the availability of advanced pre-hospital care as well as facilities for a comprehensive diagnostic evaluation of these trauma patients. In our environment, we may have missed such indications due to lack of pre-hospital rapid response mechanism.
Traditionally, TT should be inserted into the pleural cavity and directed upward, particularly if air in the pleural cavity is to be released. For fluid drainage, the fenestrations in the tube must be within the pleural cavity but lower down so as to enable the tube drain all the fluid by gravity. However, in this study, we found that those patients whose chest tube insertion was considered non-ideally placed as reported by the radiologists had similar outcome with the ones that were considered ideally placed. These non-ideal TT had few secondary interventions that only varied from observation (nothing was done) to tube reposition and to tube replacement. None had additional TT placement or thoracotomy. Therefore, suggesting that the position of the tube did not really matter as long as the most proximal (sentinel hole) fenestration was within the pleural cavity. Therefore, this finding questions the concept of many fenestrations on the tube as well as that which says the tube must lie upward within the pleural cavity. It was based on these two previous reasons that gave rise to the concept of ideal TT and non-ideal TT placement. The findings of our study corroborates the findings of many studies,, which have gradually changed many concepts related to TT. For instance, the size of the tube has been shown not to be relevant as it was previously upheld.,,, In the study done by Inaba et al., they compared small (28-32Fr) size tube and large (36-40Fr) size tube and found that there was no significant difference in their efficacies. In support of our findings, another study done by Huber-Wagner et al. found that mal-positioning (non-ideal TT), mostly interlobar, occurs in every fifth TT but all these non-ideal tubes did well without any malfunction that was significantly different from those that were well placed (ideal TT) TT. Similarly, we observed that various positional change of the patient may have facilitated drainage by the sentinel hole. The air and fluid keep changing position along with that of the patient when they lay propped up or supine. Thus, the air or the fluid often locates the sentinel hole to escape through it. Probably, this was due to uniformly patent pleural cavities that were mostly found in these patients. In fact, in the recent British Thoracic Society (BTS) guidelines for the insertion of chest drain, it is being advised that chest tube should not be repositioned simply because of suboptimal radiographic appearance except if it is not functional at all. The status of the surgeon who performed the TT appeared to have influenced the rate of secondary interventions. In our findings, TT performed by consultants and senior resident doctors were found to have been well placed (ideal TT), while the non-ideal TT were done by a junior resident doctors. This apparent difference may be due to their level of experience.
| Conclusion|| |
Position of a non-kinked TT with the sentinel hole within the pleural cavity does not affect the rate of secondary intervention, including the rate of thoracotomy. Therefore, the intrathoracic position of TT appears not to matter much as long as the sentinel hole of the tube is in the pleural cavity.
These findings must be interpreted on the basis that the pleural cavity is patent all through and free. Of course, normal pre-morbid pleural cavity is commonly found in patients with chest trauma. We are not sure if the same principles could hold for non-traumatic pleural effusion where there may be loculations of the pleural cavity from chronic chest diseases.
The small size of our sample may have some effect on the outcome of this study. Therefore, in future, there may be a need to consider doing a randomized control study to further ascertain these findings.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]