A thoracostomy is a small incision of the

chest wall The thoracic wall or chest wall is the boundary of the thoracic cavity. Structure The bone, bony human skeleton, skeletal part of the thoracic wall is the rib cage, and the rest is made up of muscle, skin, and fasciae. The chest wall has 10 lay ...

, with maintenance of the opening for

drainage Drainage is the natural or artificial removal of a surface's water and sub-surface water from an area with excess of water. The internal drainage of most agricultural soils is good enough to prevent severe waterlogging (anaerobic conditio ...

. It is most commonly used for the treatment of a

pneumothorax 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, a one-way valve ...

. This is performed by physicians, paramedics, and nurses usually via

needle thoracostomy Thoracentesis , also known as thoracocentesis (from Greek ''thōrax'' 'chest, thorax'—GEN ''thōrakos''—and ''kentēsis'' 'pricking, puncture'), pleural tap, needle thoracostomy, or needle decompression (often used term), is an invasive med ...

or an incision into the chest wall with the insertion of a

thoracostomy tube A chest tube (also chest drain, thoracic catheter, tube thoracostomy or intercostal drain) is a surgical drain that is inserted through the chest wall and into the pleural space or the mediastinum in order to remove clinically undesired substance ...

(chest tube) or with a hemostat and the provider's finger (finger thorocostomy), A thoracostomy is often confused with

thoracotomy A thoracotomy is a surgical procedure to gain access into the pleural space of the chest. It is performed by surgeons (emergency physicians or paramedics under certain circumstances) to gain access to the thoracic organs, most commonly the hea ...

, which is a larger incision commonly used to gain access to organs within the chest.

Medical uses

When air, blood, or other fluids accumulate in the

pleural cavity The pleural cavity, pleural space, or interpleural space is the potential space between the pleurae of the pleural sac that surrounds each lung. A small amount of serous pleural fluid is maintained in the pleural cavity to enable lubrication bet ...

it may be drained by thoracostomy. Whereas air in this space (

) may be released by

, other substances require drainage with a

Contra-indications

There are no absolute

contraindications In medicine, a contraindication is a condition that serves as a reason not to take a certain medical treatment due to the harm that it would cause the patient. Contraindication is the opposite of indication, which is a reason to use a certain tre ...

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.

Technique

A primary skin incision is made superiorly to the rib to avoid the neurovascular supply that runs inferiorly to the rib. The surgeon will tunnel through the subcutaneous tissue and muscle to penetrate the pleural cavity. This cavity is where a hemothorax or pneumothorax would accumulate. Confirmation of being in the pleural cavity is done and the chest tube is placed. The chest tube is then connected to a Pleur-evac for continuous drainage. A Roman sandal tie and U-Stitch are done to secure the chest tube and to ensure that removal of the tube will not produce another pneumothorax. Chest x-ray is performed post-procedure to confirm placement and to check for resolution of the pneumothorax/hemothorax. 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 A check valve, non-return valve, reflux valve, retention valve, foot valve, or one-way valve is a valve that normally allows fluid (liquid or gas) to flow through it in only one direction. Check valves are two-port valves, meaning they have t ...

, 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.

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). 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 A trocar (or trochar) is a medical or veterinary device that is made up of an awl (which may be a metal or plastic sharpened or non-bladed tip), a cannula (essentially a hollow tube), and a seal. Trocars are placed through the abdomen during lap ...

during the procedure decreases the risk of this from occurring.

References

{{Reflist Emergency medical procedures Pulmonology

Medical uses

Contra-indications

Technique

Risks/complications

See also

References