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CHAPTER 56: Thoracostomy 505

• Camargo CA Jr, Rachelefsky G, Schatz M. Managing asthma exac-
erbations in the emergency department: summary of the National water seal rather than suction. This may hasten the resolution of
Asthma Education and Prevention Program Expert Panel Report 3 leak across the visceral pleura and thus hasten chest tube removal.
guidelines for the management of asthma exacerbations. J Allergy • Chest tube removal can be considered when there is no air leak in
Clin Immunol. 2009;124(suppl 2):S5-S14. the pleural drainage system (pneumothorax) and/or there is less
• Leatherman JW, Fluegel WL, David WS, Davies SF, Iber C. Muscle than 100 to 300 mL of fluid drainage per day (effusion).
weakness in mechanically ventilated patients with severe asthma.
Am J Respir Crit Care Med. 1996;153(5):1686-1690.
• Lim WJ, Mohammed Akram R, Carson KV, et al. Non-invasive
positive pressure ventilation for treatment of respiratory failure INDICATIONS FOR THORACOSTOMY
due to severe acute exacerbations of asthma. Cochrane Database Thoracostomy tubes, alternatively called chest drains, are inserted to
Syst Rev. 2012;12:CD004360. drain fluid or air from the pleural space and remain in place until the
• Marini JJ. Dynamic hyperinflation and auto-positive end-expira- drainage is completed. The indications for thoracostomy placement differ
tory pressure: lessons learned over 30 years. Am J Respir Crit Care based on the amount of air, characteristics of the fluid as well as the
Med. 2011;184(7):756-762. clinical and physiologic consequences of these pleural space collections.
• McFadden ER Jr. Dosages of corticosteroids in asthma. Am Rev ■
Respir Dis. 1993;147(5):1306-1310. PNEUMOTHORAX
• National Asthma Education and Prevention Program (NAEPP): A pneumothorax is defined as a collection of air within the pleural
Expert Panel Report 3. Guidelines for the Diagnosis and space. Often pneumothoraces can occur in otherwise healthy people
Management of Asthma. National Heart, Lung, and Blood Institute (ie, primary spontaneous pneumothorax), but can also be postsurgical,
(NHLBI), National Institutes of Health (NIH); August 2007. iatrogenic, or related to trauma, including barotrauma from ventilator-
• Peters JI, Stupka JE, Singh H, et al. Status asthmaticus in the induced lung injury. Secondary pneumothoraces occur in the setting
medical intensive care unit: a 30-year experience. Respir Med. of underlying lung disease. Symptoms of either a primary or secondary
2012;106(3):344-348. pneumothorax can include pleuritic chest pain or dyspnea; however,
• Ramsay CF, Pearson D, Mildenhall S, Wilson AM. Oral montelu- patients with secondary pneumothorax often have shortness of breath
31,32
kast in acute asthma exacerbations: a randomised, double-blind, that is out of proportion to the size of the pneumothorax. Physical
placebo-controlled trial. Thorax. 2011;66(1):7-11. exam findings can be subtle, but can range from tachypnea and tachy-
cardia to hypotension and cardiovascular collapse. Tracheal deviation
away from the side of the pneumothorax and decreased breath sounds
on the affected side as well as subcutaneous emphysema may be present.
Imaging studies can be helpful in establishing a diagnosis. Chest com-
REFERENCES puted tomography is the gold standard for diagnosis of pneumothorax.

Complete references available online at www.mhprofessional.com/hall Indeed, nearly 40% of traumatic pneumothoraces are not clinically
apparent. Chest roentography is a common method of identifying a
1
pneumothorax once it is suspected clinically. Fully upright posteroan-
terior and lateral films are the most accurate roentographic method to
Thoracostomy identify a pneumothorax, although these are sometimes challenging to
CHAPTER obtain, particularly in critically ill patients. A pneumothorax is identi-
fied by the presence of a dense white line with the absence of vascular
56 Shruti B. Patel markings lateral to it. At times, the patient’s positioning or lung pathol-
John F. McConville
ogy can cause collection of the air in either the anterior chest or along
the costodiaphragmatic angle, creating a “deep sulcus” sign (Fig. 56-1).
The use of ultrasound to image the lung and pleural space has become
increasingly common. Ultrasound can be used by clinicians at the bed-
KEY POINTS side to detect pneumothorax as soon as consistent signs/symptoms are
identified. The interface between the aerated lung and the chest wall is
• Pneumothorax in critically ill patients is often missed with con-
ventional chest radiography. Ultrasound is a more reliable means readily visualized and often referred to as the pleural line. If this struc-
ture can be seen moving with respiratory variation, often referred to as
of detecting pneumothorax. lung sliding, then pneumothorax can be ruled out at that position.
3,28
• Pleural effusions can be detected by chest radiograph, chest CT When the lung is imaged via ultrasound using the M-mode, or
and ultrasound. Ultrasound can be used for real time guidance of motion-mode, a normal lung demonstrates a seashore sign in which
thoracentesis and chest tube placement. the lung appears grainy against the solid straight lines of the chest wall
• Empyema is the presence of pus within the pleural space and should (Fig. 56-2). A pneumothorax appears as solid straight lines throughout
be treated with systemic antibiotics as well as insertion of a chest drain. the whole ultrasound field as is often referred to as the stratosphere or
Other relative indications for placement of a chest drain include: posi- barcode sign (Fig. 56-3). Often, the transition between fully inflated
tive gram stain or culture of pleural fluid and/or pH <7.2. lung and a pneumothorax can be identified: this is called the lung
• Recurring pleural effusions (eg, malignancy) can be managed by point (Fig. 56-4). It is characterized by normal sliding lung immedi-
placement of a tunneled drainage system or pleurodesis (chemical ately adjacent to nonsliding lung. When M-mode is used to identify
or surgical). the lung point, the operator should visualize alternating seashore and
• Pleurodesis is extremely painful and should always be preceded by stratosphere signs as the normal lung moves in and out of view. If the
lung point can be found, it is highly specific for the presence of a pneu-
aggressive anesthesia and analgesia. mothorax. Furthermore, by scanning across the entire hemithorax, the
4
• Chest tubes placed for pneumothorax should be evaluated daily lung point can be used to quantify the size of a pneumothorax. When
5
for air leak. Pleural drainage systems can usually be placed on compared to the gold standard of chest computed tomography, ultra-
sound is highly sensitive (86%-98%) and highly specific (97%-100%).
5,6

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