Lung perforation complicating tube thoracostomy: Pathologic description of three cases

doi:10.1016/S0046-8177(88)80197-7

Human Pathology

Volume 19, Issue 5, May 1988, Pages 518-523

https://doi.org/10.1016/S0046-8177(88)80197-7 Get rights and content

Insertion of a chest tube into the pleural space is standard therapy for a variety of pleural abnormalities. Three cases are described of lung perforation secondary to this procedure. In all three cases the tube had been inserted with the use of a trocar, and in two there were pleural adhesions in the vicinity of the puncture; in none was the perforation suspected clinically or considered to contribute to patient death. Pathologic features included one or two pleural holes continuous with a parenchymal tract of variable length. In one case, there was early epithelialization of the inner surface of the tract, suggesting that some of these may remain patent and be seen as incidental findings long after their formation. Two of the cases were identified among 18 patients who had had chest tubes inserted and came to autopsy over a similar period, implying that the incidence of the complication is greater than is generally appreciated. Reasons for this under appreciation are the lack or nonspecificity of clinical and radiographic findings and the ease with which perforation can be overlooked at autopsy.

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Parenchymal injury and resulting tube malposition occurred in 1 case in each group. Intraparenchymal TT is more likely to occur with pre-existing pulmonary disease or pleural adhesions [13]. This finding was reflected in the case of tube malposition in the VTT group where parenchymal injury occurred at thoracostomy in a patient who had undergone previous VATS pleurodesis.
Complications related to incorrect positioning of tube thoracostomy (TT) have been reported to be as high as 30%. The aim of this study was to assess the feasibility of flexible videoscope guided placement of a pre-loaded chest tube, permitting direct intrapleural visualization and placement (Video-Tube Thoracostomy [V-TT]).
A prospective, single centre, phase 1 pilot study with a parallel control group was undertaken. The population studied were adult thoracic trauma patients requiring emergency TT who were haemodynamically stable. The intervention performed was VTT. Patients in the control group underwent conventional TT. The primary outcome was tube position as defined by a consultant radiologist’s interpretation of chest x-ray (CXR) or CT. The trial was registered with ANZCTR.org.au (ACTRN: 12,615,000,870,550).
There were 37 patients enrolled in the study - 12 patients allocated to the VTT intervention group and 25 patients allocated to conventional TT. Mean age of participants was 48 years (SD 15) in intervention group and 46 years (SD 15) years in the control group.
In the VTT group all patients were male; the indications were pneumothorax (83%), haemothorax (8%) and haemopneumothorax (8%). The median injury severity score was 23 (16–28). There were 1 positional and 1 insertional complications. In the control group 72% of patients were male, the indications were pneumothorax (56%), haemothorax (4%) and haemopneumothorax (40%). The median injury severity score was 24 (14–36). There were 8 (32%) positional complications and no insertional complications.
V-TT was demonstrated to be a feasible alternative to conventional thoracostomy and merits further investigation.
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The chest tube is left in the pleural space and the trocar withdrawn. Although technically simple, this “harpoon” technique has a high risk of complications, mainly because of the danger of impaling the lung or surrounding organs.3,13–15 Hence, in the authors’ opinion, these tubes are not recommended for routine use.
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This review examines pleural decompression and drainage during initial hospital adult trauma reception and resuscitation, when it is indicated for haemodynamically unstable patients with signs of pneumothorax or haemothorax. The relevant historical background, techniques, complications and current controversies are highlighted.
Key findings of this review are that:
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  Needle thoracocentesis is an unreliable means of decompressing the chest of an unstable patient and should only be used as a technique of last resort.
- 2.
  Blunt dissection and digital decompression through the pleura is the essential first step for pleural decompression, as decompression of the pleural space is a primary goal during reception of the haemodynamically unstable patient with a haemothorax or pneumothorax. Drainage and insertion of a chest tube is a secondary priority.
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  Techniques to prevent tube thoracostomy (TT) complications include aseptic technique, avoidance of trocars, digital exploration of the insertion site and guidance of the tube posteriorly and superiorly during insertion.
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Pneumothorax is present in about 20% of blunt major trauma cases. Insertion of an intercostal tube drainage is one effective treatment, however it is unclear whether the thoracostomy has more advantages if placed in the ventral (2.–3. intercostal space) or lateral (4.–6. intercostal space) approach. The aim of this study was to determine, whether there are any differences between the two approaches in respect of malposition and complications.
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Clinically relevant malfunction was diagnosed in 6 of the 22 malpositioned chest tubes (5.9%). These tubes had to be repositioned, one was placed ventrally, the other five were placed laterally.
In our setting physicians preferred the lateral approach on-scene as well as in-hospital. In every fifth patient malpositioning of the tube was observed, mostly interlobal after lateral chest tube, however only few were associated with relevant clinical malfunctions. The probability of interlobal malpositioning is significantly higher when using the lateral approach as opposed to the ventral approach. Correction of malpositioned and ineffective chest tubes was necessary in every 17th case. No statistically significant difference between the two approaches for functional malposition was observed. Hence both approaches for emergency chest tube insertion seem to be equally justified.
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¹: From the Department of Pathology, Montreal General and Montreal Chest Hospitals and McGill University, Montreal, Quebec, Canada.

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Lung perforation complicating tube thoracostomy: Pathologic description of three cases

Chest

Emerg Med Clin North Am

J Thorac Cardiovasc Surg

Ann Emerg Med

Am J Surg