uma &

Walker, et al., J Trauma Treat 2015, 4:2

Tra
of
Tr
DOI: 10.4172/2167-1222.1000247

ea
l

Journal of Trauma & Treatment

Journa

tme
ISSN:2167-1222
ISSN: 2167-1222 nt

Research
Research Article
Article Open
OpenAccess
Access

Lateral Thoracostomy Tubes: Is Outcome Affected by Level of Intercostal

Space?
Kyle E Walker1, Elaine Pahilan M2, Carlos Previgliano3 and Asser M Youssef2,4*
1
Louisiana State University Health Sciences Center Shreveport, Louisiana, USA
2
Department of Surgery, Louisiana State University Health Sciences Center- Shreveport, Louisiana, USA
3
Department of Radiology, Louisiana State University Health Sciences Center- Shreveport, Louisiana, USA
4
Chandler Regional Medical Center, Chandler, Arizona, USA

Abstract
Objectives: Tube thoracostomy is a common procedure performed after chest trauma. The current practice is to
insert the tube in the 3rd, 4th, or 5th intercostal space (ICS) at the anterior axillary line. In this study we compared the
outcome of tubes inserted at lower spaces versus the standard (higher) location.
Methods: Patients receiving a chest tube after chest trauma were identified using the trauma registry at a Level
1 trauma center from July 2009 to December 2011. Each tube inserted was categorized as either “High” (3rd-5th ICS)
or “Low” (6th-7th ICS) placement. Patient records were reviewed for demographics, Injury Severity Score (ISS), chest
tube interval (CTI), length of hospital stay (LOHS), interventions (including thoracoscopy and thoracotomy), and
mortality.
Results: There were no differences between both groups regarding age, ISS, interventions or mortality. However,
patients receiving chest tubes in the 3rd through-5th ICS (High group) demonstrated significantly lower CTI and LOHS
when controlling for age and ISS. (Multi-linear Regression, F-Value=3.14 and 9.44; p=0.027 and <0.0001, respectively)
Conclusion: Low thoracotomy placement tubes are as safe as High placement with no difference in outcome in terms
of morbidity and mortality. However, patients with low placement reported longer CTI and a longer LOHS. 

Keywords: Hemopneumothorax; Thoracostomy; Injury severity This study was approved by the Institutional Review Board of the
score Louisiana State Health Sciences Center, Shreveport, Louisiana.

Introduction Patients with bilateral chest tubes yielded two data points. Each
chest tube placement was categorized as either High (chest tube
Tube thoracostomy is a procedure frequently performed in medical placement in the 3rd, 4th, or 5th intercostal space) or Low (chest tube
centers. Indications for tube thoracostomy include pneumothorax, placement in the 6th or 7th intercostal space). Chest tube interval (CTI)
hemopneumothorax, and postoperative drainage [1,2]. While the was defined as the duration of the chest tube insertion. The standard
lifesaving potential of this procedure is very high, it is not without risk practice at our facility is that patients who receive chest tubes should
of complications. The most common complications following tube be evaluated daily by chest x-ray. Therefore, each tube was categorized
thoracostomy are positional (i.e. kinking, malposition) and infective, to their relevant positions based on chest x-ray and was confirmed
however insertional (i.e. structural trauma) complications can also by computed tomography (CT) when available. A board-certified
occur [2]. Infections, when they occur, have a tendency to be drain radiologist then reviewed each tube categorization for verification of
site infections which are minor in nature. Clinically major infections the ICS location. Outcome variables measured included indication
such as an empyema have a relatively low incidence rate [3]. While for tube placement, chest tube interval (CTI), length of hospital stay
lateral placement seems to be preferred by most physicians, there is no (LOHS), mortality, the need for any related intervention (replacement,
clinically significant difference between ventral and lateral placement of adjustment of malposition, placement of second chest tube), and the
chest tubes [4]. Lateral chest tube placement is associated with a higher need for surgical intervention (Video-assisted thoracoscopic surgery
rate of interlobar positioning, however studies have shown that there (VATS), Thoracotomy) and complications. Similarly to the study
is no loss of function related to placement within the pleural fissure performed by Bailey, complications were classified as insertional,
[4,5]. While many health care practitioners believe lower chest tubes positional, or infective [3]. Demographic data studied included
are superior for draining fluid, and resulting in reduced risk of retained age, race, gender, injury class and mechanism, prior injuries, Injury
hemothorax and empyema, others are concerned that inserting low
tubes carry the risk of injury to diaphragm and intra-abdominal
organs. The purpose of this study is to compare the complication rates *Corresponding author: Asser M Youssef, Chandler Regional Medical Center, 485
of thoracostomy tube placed after chest trauma at a current standard S Dobson Rd, Suite 201, Chandler, AZ 85224, Tel: +1 480-728-3000; USA, E-mail:
practice, high placement (3-5thICS), versus low (6-7th ICS) placement [email protected]
and to determine if a lower placement yields better outcomes. Received January 30, 2015; Accepted April 15, 2015; Published April 17, 2015

Citation: Walker KE, Pahilan ME, Previgliano C, Youssef AM (2015) Lateral

Materials and Methods Thoracostomy Tubes: Is Outcome Affected by Level of Intercostal Space?. J
Trauma Treat 4: 247. doi:10.4172/2167-1222.1000247
Between July 1, 2009 and December 31, 2011 non-incarcerated
trauma patients between the ages of 18 and 80 that received a de novo Copyright: © 2015 Walker KE, et al. This is an open-access article distributed
chest tube for pneumothorax, hemothorax, and/or hemopneumothorax under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the
were identified using the trauma registry (TraumaOne, Version 4.10). original author and source are credited.

J Trauma Treat
ISSN: 2167-1222 JTM, an open access journal Volume 4 • Issue 2 • 1000247
Citation: Walker KE, Pahilan ME, Previgliano C, Youssef AM (2015) Lateral Thoracostomy Tubes: Is Outcome Affected by Level of Intercostal Space?.
J Trauma Treat 4: 247. doi:10.4172/2167-1222.1000247

Page 2 of 3

Severity Score (ISS) and Abbreviated Injury Severity Score (AIS). We Variable Chi-Square P-Value
used ISS and AIS because these are most standardized anatomical All Interventions* 0.0183 0.8924
scoring system which correlates with the severity of injury. Descriptive Surgical Interventions** 1.0329 0.3095
analyses for continuous variables are presented as mean with standard Mortality 0.1356 0.7127
deviation and as frequencies with percentages for categorical variables. *All Interventions include: Replacement of Chest Tube, Addition of Second Chest
For continuous variables, independent Student’s t-tests were used to Tube, and Surgical Interventions**
compare mean differences, while the Chi-square test used to analysis. **Surgical Interventions Include: VATS, Thoracotomy
P-values of less than 0.05 were considered statistically significant. All Table 2: Table of Chi-Square results comparing frequencies in high and low chest
statistical analysis were performed using Statistical Analysis Software tube placement groups.
(SAS 9.2, Cary, NC). intercostal level of tube placement. The current recommendation is to
achieve a position in what was described as the “safe triangle” which
Results
encompasses the 3rd through 5th intercostal spaces [6]. Such placement
The trauma registry inquiry yielded 161 patients that met the is thought to decrease various complications associated with lateral
criteria listed above. A total of 17 patients were excluded due to death tube placement including pulmonic perforation [7] cardiac perforation
within 48 hours of admission. All deaths were related to severity of [8-10] neurovascular injury [11-13] intra-abdominal placement and
injury and there were no complications associated with thoracostomy diaphragmatic injury [14-18]. The latter two complications are of
tube recorded prior to death. Another 10 patients were not included due particular concern with lower tube placement due to the proximity of
to incomplete medical records and one additional patient was excluded the diaphragm and abdominal cavity to the lower intercostal spaces. It
for tampering with his chest tube. A total of 133 patients were analyzed, is of note, however, that no diaphragmatic injuries or intra-abdominal
29 of which received bilateral chest tube placement. A total of 162 chest placements were observed in our study among those patients who
tube placements were observed as eligible for this study. While some had lower tubes. According to the British Thoracic Society (BTS)
patients may have been given antibiotics during their hospitalization guidelines, the “safe triangle” is the area contained posteriorly by the
for treatment of other ailments, no patients were recorded as having latissimus muscle, laterally by the pectoralis major muscle, inferiorly by
been given prophylactic antibiotics. The patients’ medical records were an imaginary line drawn from the horizontal level of the nipple, and an
reviewed to determine age, race, sex, mechanism of injury, indication apex slightly below the axilla which correlates to high placement.
for tube placement, CTI, LOHS, ISS, AIS, complications, as well as
The ideal position for the patient during chest tube insertion is one
post-placement interventions (i.e. surgical interventions, placement
in which the patient is tilted slightly to opposite side to that which the
of second chest tube, and replacement after removal). Surgical
tube is to be placed, while the ipsilateral arm is abducted toward the
interventions (i.e. VATs, thoracotomy) were also compared separately
patient’s head [6-8]. After the patient is positioned and an appropriately
from other interventions.
sized drain is chosen, the chest wall is prepped, adequate local
The mechanism of injury in the majority of the patients in the anesthetic used and a 2to 3 cm incision made careful blunt dissection is
study was related to motor vehicle crashes. Of the 162 observations, utilized and the tube introduced. The tube is then secured to the patient
112 were categorized as High and 50 were classified as Low. Average with suture. Once the tube is placed and secured, it can be attached
CTI for the High versus Low placement groups was 8.34 ± 5.33 days to a closed water seal system or directly to suction based on physician
and 10.68 ± 7.39 days, respectively. The average LOHS for the High discretion [8]. Aseptic technique with full barrier precautions should be
placement group was 15.36 days ± 12.82 days, versus 25.16 ± 21.37 days emphasized during the procedure. A chest x-ray is preformed following
for the Low placement group. Among those patients receiving a high the procedure to screen for malposition or other complications
placement tubes, 28 (25.0%) received some type of intervention and associated with the insertion. While the CT scan has proven an accurate
8 received surgical intervention. Comparatively, 13 interventions and tool to assess the position of thoracostomy tubes, radiographs are more
6 surgical interventions were performed on patients with low placed cost effective and have been shown to be sufficient in thoracostomy
tubes. Patients with chest tubes in the 3rd, 4th, or 5th intercostal space tube evaluation [9,10].
had significantly lower chest tube durations, controlling for age and ISS
Development of an empyema is a highly concerning complication
(Multi-linear Regression, F-Value=3.14, p=0.027). These patients also
that can occur with any insertional approach. The occurrence of
demonstrated a significantly shorter LOHS, controlling for age and
ISS (Multi-linear Regression, F-Value=9.44, p<0.0001) There were no empyema seems to be more highly associated with hemothorax than
differences between the placement groups in regards to age, ISS, need pneumothorax [19,20] and rates are reported to vary between 4% and
for further intervention, need for surgical intervention or mortality 10% [21-23]. Empyema is a particularly prevalent risk in the presence of
(Tables 1 and 2). retained hemothorax as the nutrients provided by the remaining blood
products are ideal for bacterial growth. In comparison to previousely-
Discussion reported incidence rates, our data yielded an empyema rate of 4.46%
with higher tube placement and 6% with lower placement. Recent
While studies have shown that there is no significant difference
studies are inconclusive as to the benefits of prophylactic antibiotic use in
in outcomes of lateral versus ventral tube placement, [4,5] no studies
patients with thoracostomy tubes [24]. No prophylactic antibiotics were
have assessed outcomes, in particular complications rates, based on the
used in our patients. Some physicians believe that, with the assistance
Variable T-Value P-Value
of gravity, lower placed tubes would be more efficient at resolving
ISS -0.54 0.5929
hemothoraces and thus prevent empyema formation. However, our
Age -1.86 0.0650
data showed no statistical difference in the rates of empyema formation
Duration of Insertion -2.01 0.0483
when comparing higher and lower intercostal tube placement.
Length of Stay -3.01 0.0037 Moreover, when comparing the need for all or surgical intervention,
Table 1: T-test results comparing high and low chest tube placement. there was no statistical difference between the two groups. There was also

J Trauma Treat
ISSN: 2167-1222 JTM, an open access journal Volume 4 • Issue 2 • 1000247
Citation: Walker KE, Pahilan ME, Previgliano C, Youssef AM (2015) Lateral Thoracostomy Tubes: Is Outcome Affected by Level of Intercostal Space?.
J Trauma Treat 4: 247. doi:10.4172/2167-1222.1000247

Page 3 of 3

no difference in ISS, age, and mortality demonstrated between levels of 4. Huber-Wagner S, Körner M, Ehrt A, Kay MV, Pfeifer KJ, et al. (2007) Emergency
chest tube placement in trauma care - which approach is preferable?
placement. Interestingly, our data showed that patients receiving lower
Resuscitation 72: 226-233.
chest tubes had both a longer CTI and longer LOHS. The discrepancy
between the two groups is postulated to be a surrogate marker for 5. Curtin JJ, Goodman LR, Quebbeman EJ, Haasler GB (1994) Thoracostomy
tubes after acute chest injury: relationship between location in a pleural fissure
another underlying factor. Age was the first factor considered since and function. AJR Am J Roentgenol 163: 1339-1342.
our t-test data revealed a p-value approaching statistical significance
6. Webb WR, LaBerge JM (1984) Radiographic recognition of chest tube
with older patients receiving lower tube placement. However, after malposition in the major fissure. Chest 85: 81-83.
controlling for both age and ISS our data yielded the same results.
7. Tomlinson MA, Treasure T (1997) Insertion of a chest drain: how to do it. Br J
Body habitus (i.e. obesity) has been shown to be an independent risk
Hosp Med 58: 248-252.
for increased LOHS and could possibly be associated with lower level
of insertion as the body habitus associated with obesity may also be 8. Iberti TJ, Stern PM (1992) Chest tube thoracostomy. Crit Care Clin 8: 879-895.
associated with a relatively lower nipple line used in determining the 9. Stark DD, Federle MP, Goodman PC (1983) CT and radiographic assessment
base of the ‘safe triangle’. Furthermore, our data approached clinical of tube thoracostomy. AJR Am J Roentgenol 141: 253-258.
significance regarding older patients who were more likely to receive 10. Landay M, Oliver Q, Estrera A, Friese R, Boonswang N, et al. (2006) Lung
a lower tube placement. Although age was controlled for in our multi- penetration by thoracostomy tubes: imaging findings on CT. J Thorac Imaging
linear regression analysis, the trend toward statistical significance when 21: 197-204.

examining older patients may further validate the theory that changes 11. Meisel S, Ram Z, Priel I, Nass D, Lieberman P (1990) Another complication of
in body habitus (either due to age, obesity, or both) may be associated thoracostomy--perforation of the right atrium. Chest 98: 772-773.
with a lower tube placement. Another cofounding factor could be 12. Kollef MH, Dothager DW (1991) Reversible cardiogenic shock due to chest
physician preference. tube compression of the right ventricle. Chest 99: 976-980.

13. Butler KL, Best IM, Weaver WL, Bumpers HL (2003) Pulmonary artery injury
Our study was limited by lack of sufficient data needed to adequately and cardiac tamponade after needle decompression of a suspected tension
explore the body habitus of the patient receiving a thoracostomy tube pneumothorax. J Trauma 54: 610-611.
or the identity of the inserting physician. However, our study was
14. Campbell P, Neil T, Wake PN (1989) Horner’s syndrome caused by an
sufficiently powered at the alpha=0.05 level with power at 80%. intercostal chest drain. Thorax 44: 305-306.

Conclusion 15. Millikan JS, Moore EE, Steiner E, Aragon GE, Van Way CW 3rd (1980)
Complications of tube thoracostomy for acute trauma. Am J Surg 140: 738-
Our investigation illustrated that a majority (2:1) of tubes are placed 741.
in the 3rd through 5th intercostal spaces, which coincided with current 16. Hyde J, Sykes T, Graham T (1997) Reducing morbidity from chest drains. BMJ
recommendations to approach insertion through the “safe triangle”. 314: 914-915.
However, there is no significant difference in mortality, surgical 17. Foresti V, Villa A, Casati O, Parisio E, De Filippi G (1992) Abdominal placement
intervention, or total interventions when higher (ICSs 3rd through of tube thoracostomy due to lack of recognition of paralysis of hemidiaphragm.
5th) and lower (ICSs 6th through 7th) placement is compared. Patients Chest 102: 292-293.
who received lower tube placement demonstrated both an extended 18. Maxwell RA, Campbell DJ, Fabian TC, Croce MA, Luchette FA, et al. (2004)
duration of insertion and LOHS. This, however, is considered to be a Use of presumptive antibiotics following tube thoracostomy for traumatic
hemopneumothorax in the prevention of empyema and pneumonia--a multi-
surrogate marker for an unexamined factor. As such, it is a reasonable
center trial. J Trauma 57: 742-748.
assumption that lower intercostal space chest tube placement when
compared to higher intercostal space placement is equally efficacious 19. Eren S, Esme H, Sehitogullari A, Durkan A (2008) The risk factors and
management of posttraumatic empyema in trauma patients. Injury 39: 44-49.
and, when performed by a well-trained physician, offers no increase
in adverse outcomes or clinical interventions required. A prospective 20. Karmy-Jones R, Holevar M, Sullivan RJ, Fleisig A, Jurkovich GJ (2008)
Residual hemothorax after chest tube placement correlates with increased risk
controlled study is needed to confirm our findings. of empyema following traumatic injury. Can Respir J 15: 255-258.

Conflicts of Interest 21. Richardson JD, Carrillo E (1997) Thoracic infection after trauma. Chest Surg
Clin N Am 7: 401-427.
All of the authors on this manuscript are without any known
22. Fallon WF Jr (1994) Post-traumatic empyema. J Am Coll Surg 179: 483-492.
conflicts of interest that could bias the information obtained from this
study. Additionally, no study sponsors were utilized in any aspect of 23. Moore, FO, TM Duane (2012) Presumptive antibiotic use in tube thoracostomy
for traumatic hemopneumothorax: an Eastern Association for the Surgery
this work, including, but not limited to, data collection, analysis of data, of Trauma practice management guideline. J Trauma Acute Care Surg.
writing of manuscript, or submission for publication. S341-S314.

24. Hauck K, Hollingsworth B (2010) The impact of severe obesity on hospital

Acknowledgement
length of stay. Med Care 48: 335-340.
The authors of this paper would like to acknowledge Jeanette Ward and Tali-
cia Tarver for their assistance.

References
1. Laws D, Neville E, Duffy J; Pleural Diseases Group, Standards of Care
Committee, British Thoracic Society (2003) BTS guidelines for the insertion of
a chest drain. Thorax 58 Suppl 2: ii53-59.

2. Khanzada TW, Samad A (2008) Indications and complications of tube

thoracostomy performed by general surgeons. J Pak Med Assoc 58: 39-40.

3. Bailey RC1 (2000) Complications of tube thoracostomy in trauma. J Accid

Emerg Med 17: 111-114.

J Trauma Treat
ISSN: 2167-1222 JTM, an open access journal Volume 4 • Issue 2 • 1000247