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Shah A, Naselsky W, Dave S, Young BA, Bittle G, Tabatabai A, Friedberg J, Krause E. Pneumothorax in acute respiratory distress syndrome on extracorporeal membrane oxygenation support. Perfusion 2024; 39:776-783. [PMID: 36877783 DOI: 10.1177/02676591231159559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
INTRODUCTION Pneumothorax is associated with poor prognosis in patients with acute respiratory distress syndrome (ARDS). We sought to examine the outcomes of patients who are supported on veno-venous extracorporeal membrane oxygenation (VV ECMO) and develop a pneumothorax. METHODS We retrospectively reviewed all adult VV ECMO patients supported for ARDS between 8/2014-7/2020 at our institution, excluding patients with recent lung resection and trauma. Clinical outcomes were compared between patients with a pneumothorax to those without a pneumothorax. RESULTS Two hundred eighty patients with ARDS on VV ECMO were analyzed. Of those, 213 did not have a pneumothorax and 67 did. Patients with a pneumothorax had a longer duration of ECMO support (30 days [16-55] versus 12 [7-22], p < 0.001) and hospital length of stay (51 days [27-93] versus 29 [18-49], p < 0.001), and lower survival-to-discharge (58.2% versus 77.5%, p = 0.002) compared to patients without a pneumothorax. Controlling for age, BMI, sex, RESP score and pre-ECMO ventilator days, the odds ratio of survival-to-discharge was 0.41 (95% CI 0.22-0.78) in patients with a pneumothorax compared to those without. There was a lower incidence of significant bleeding when chest tubes were placed by proceduralist services (2.4% versus 16.2%, p = 0.03). Removal of the chest tube prior to ECMO decannulation compared to removal after decannulation was associated with need for replacement (14.3% versus 0%, p = 0.01). CONCLUSION Patients who develop a pneumothorax and are supported with VV ECMO for ARDS have longer duration on ECMO and decreased survival. Further studies are needed to assess risk factors for development of pneumothorax in this patient population.
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Affiliation(s)
- Aakash Shah
- Department of Cardiac Surgery, Division of Thoracic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Warren Naselsky
- Department of Cardiac Surgery, Division of Thoracic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sagar Dave
- Department of Emergency Medicine and Anesthesia, Division of Critical Care, Emory University School of Medicine, Atlanta, GA, USA
| | - Bree Ann Young
- Department of Cardiac Surgery, Division of Thoracic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gregory Bittle
- Department of Cardiac Surgery, Division of Thoracic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ali Tabatabai
- Department of Medicine, Division of Pulmonary and Critical Care, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Joseph Friedberg
- Department of Surgery, Division of Thoracic Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Eric Krause
- Department of Cardiac Surgery, Division of Thoracic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
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Takeda K, Kasai H, Shimizu I, Hirama R, Hayama N, Shikano K, Abe M, Naito A, Suzuki T. Complications Rate and a Multidimensional Analysis of Their Causes of Tube Thoracostomy: A Mixed-Methods Study. Cureus 2024; 16:e58563. [PMID: 38765428 PMCID: PMC11102531 DOI: 10.7759/cureus.58563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2024] [Indexed: 05/22/2024] Open
Abstract
INTRODUCTION Tube thoracostomy (TT) complications are common in respiratory medicine. However, the prevalence of complications and risk factors is unknown, and data on countermeasures are lacking. METHODS This was a mixed-methods retrospective observational and qualitative study. This retrospective observational study included TT performed on patients admitted to the Department of Respiratory Medicine at our University Hospital between January 1, 2019, and August 31, 2022 (n=169). The primary endpoint was the incidence of TT-related complications. We reviewed the association between complications and patient- and medical-related factors as secondary endpoints. In this qualitative study, we theorized the background of physicians' susceptibility to TT-related complications based on the grounded theory approach. RESULTS Complications were observed in 20 (11.8%) of the 169 procedures; however, they were unrelated to 30-day mortality. Poor activities of daily living (odds ratio 4.3, p=0.007) and regular administration of oral steroids (odds ratio 3.1, p=0.025) were identified as patient-related risk factors. Physicians undergoing training caused the most complications, and the absence of a senior physician at the procedure site (odds ratio 3.5, p=0.031) was identified as a medical risk factor. Based on this qualitative study, we developed a new model for TT complication rates consistent with the relationship between physicians' professional skills, professional identity, and work environments. CONCLUSIONS Complications associated with TT are common. Therefore, it is necessary to implement measures similar to those identified in this study. Particularly, a supportive environment should be established for the training of physicians.
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Affiliation(s)
- Kenichiro Takeda
- Department of Respirology, Chiba University Graduate School of Medicine, Chiba, JPN
| | - Hajime Kasai
- Department of Respirology, Chiba University Graduate School of Medicine, Chiba, JPN
- Department of Medical Education, Chiba University Graduate School of Medicine, Chiba, JPN
| | - Ikuo Shimizu
- Department of Medical Education, Chiba University Graduate School of Medicine, Chiba, JPN
- Department of Quality and Patient Safety, Chiba University Hospital, Chiba, JPN
| | - Ryutaro Hirama
- Department of Respirology, Chiba University Graduate School of Medicine, Chiba, JPN
| | - Nami Hayama
- Department of Respirology, Chiba University Graduate School of Medicine, Chiba, JPN
| | - Kohei Shikano
- Department of Respirology, Chiba University Graduate School of Medicine, Chiba, JPN
| | - Mitsuhiro Abe
- Department of Respirology, Chiba University Graduate School of Medicine, Chiba, JPN
| | - Akira Naito
- Department of Respirology, Chiba University Graduate School of Medicine, Chiba, JPN
| | - Takuji Suzuki
- Department of Respirology, Chiba University Graduate School of Medicine, Chiba, JPN
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Tokuno J, Valanci-Aroesty S, Uchino H, Ghitulescu G, Sirois C, Kaneva P, Fried GM, Carver TE. Teaching Chest Tube Insertion by Blended Learning: A Multi-Dimensional Analysis. Surg Innov 2024; 31:92-102. [PMID: 37955277 PMCID: PMC10773156 DOI: 10.1177/15533506231211049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
BACKGROUND Emerging technologies are being incorporated in surgical education. The use of such technology should be supported by evidence that the technology neither distracts nor overloads the learner and is easy to use. To teach chest tube insertion, we developed an e-learning module, as part of a blended learning program delivered prior to in-person hands-on simulation. This pilot study was aimed to assess learning effectiveness of this blended learning, and cognitive load and the usability of e-learning. METHODS The interactive e-learning module with multimedia content was created following learning design principles. In advance of the standard simulation, 13 first-year surgical residents were randomized into two groups: 7 received the e-learning module and online reading materials (e-learning group); 6 received only the online reading materials (controls). Knowledge was evaluated by pre-and post-tests; technical performance was assessed using a Global Rating Scale by blinded assessors. Cognitive load and usability were evaluated using rating scales. RESULTS The e-learning group showed significant improvement from baseline in knowledge (P = .047), while controls did not (P = .500). For technical skill, 100% of residents in the e-learning group reached a predetermined proficiency level vs 60% of controls (P = .06). The addition of e-learning was associated with lower extrinsic and greater germane cognitive load (P = .04, .03, respectively). Usability was evaluated highly by all participants in e-learning group. CONCLUSION Interactive e-learning added to hands-on simulation led to improved learning and desired cognitive load and usability. This approach should be evaluated in teaching of other procedural skills.
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Affiliation(s)
- Junko Tokuno
- Steinberg Centre for Simulation and Interactive Learning, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | | | - Hayaki Uchino
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
| | | | - Christian Sirois
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Pepa Kaneva
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University, Health Centre, Montreal, Quebec, Canada
| | - Gerald M. Fried
- Steinberg Centre for Simulation and Interactive Learning, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Tamara E. Carver
- Steinberg Centre for Simulation and Interactive Learning, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
- Department of Surgery, McGill University, Montreal, Quebec, Canada
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Hegde S, Hofman E, Dubagunta S, Awad D, Khan O, Eisaman K, Hossain I, Walker J, Sherman B, Kadakia Y, Najjar A, Park C. Implementation of a novel thoracostomy tube trainer with real-time feedback. Trauma Surg Acute Care Open 2023; 8:e001131. [PMID: 38115971 PMCID: PMC10729290 DOI: 10.1136/tsaco-2023-001131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 11/15/2023] [Indexed: 12/21/2023] Open
Abstract
Objectives Simulation-based training leads to improved clinical performance but may be influenced by quality and frequency of training. Within simulation training, chest tube insertion remains a challenge as one of the main pitfalls of insertion is a controlled pleural entry. This study evaluates the efficacy of a novel training model with real-time pressure monitoring, the average force to pleural entry in a model and the utility of audio and visual feedback. Methods This proprietary training model comprised a modified Kelly clamp device with three force sensors at the index finger (sensor 1) and two finger loops (sensors 2 and 3), and a manikin with a replaceable chest wall pad. Standard force values (Newtons (N)) were obtained by experts; expert data revealed that 3-5 s was an acceptable time range to complete the chest tube insertion. Participant level ranged from Post-graduate Year (PGY)-1 to PGY-6 with 13 total participants. Each individual was provided an introduction to the procedure and chest tube trainer. Force (N) and time (ms) measurements were obtained from entry through dermis to pleural space puncture. A significant pressure drop suggested puncturing through the chest wall (completion of the procedure). Results Force data were captured during each phase of the procedure-linear, plateau, and drop. Linear phase (~3000 ms) was from start of procedure to point of maximum force (<30 N). Plateau phase was from maximum force to just before a drop in pressure. Drop phase was a drop in pressure by 5+ N in a span of 150 ms signaling completion of procedure. All participants were able to complete the task successfully. Force for pleural entry ranged from 17 N to 30 N; time to pleural entry ranged from 7500 to 15 000 ms. There was variability in use of all three sensors. All participants used the index sensor, however there was variability in the use of the loop sensors depending on the handedness of the participant. Left-handed users relied more on sensors 1 and 3 while right-handed users relied more on sensors 1 and 2. Given this variability, only force measurements from sensor 1 were used for assessment. Conclusions This novel force-sensing chest tube trainer with continuous pressuring monitoring has a wide range of applications in simulation-based training of emergency surgical tasks. Next steps include evaluating its impact on accuracy and efficiency. Applications of real-time feedback measuring force are broad, including vascular access, trocar placement and other common procedures. Level of evidence Level IV, prospective study.
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Affiliation(s)
- Shruti Hegde
- Surgery, The University of Texas Southwestern Medical Center Medical School, Dallas, Texas, USA
| | - Emily Hofman
- Department of Engineering, The University of Texas at Dallas, Richardson, Texas, USA
| | - Sruthi Dubagunta
- Department of Engineering, The University of Texas at Dallas, Richardson, Texas, USA
| | - Daniel Awad
- Department of Engineering, The University of Texas at Dallas, Richardson, Texas, USA
| | - Omar Khan
- Department of Engineering, The University of Texas at Dallas, Richardson, Texas, USA
| | - Kraigen Eisaman
- Department of Engineering, The University of Texas at Dallas, Richardson, Texas, USA
| | - Ifti Hossain
- Department of Engineering, The University of Texas at Dallas, Richardson, Texas, USA
| | - James Walker
- Surgery, The University of Texas Southwestern Medical Center Medical School, Dallas, Texas, USA
| | - Bradley Sherman
- Surgery, The University of Texas Southwestern Medical Center Medical School, Dallas, Texas, USA
| | - Yash Kadakia
- Surgery, The University of Texas Southwestern Medical Center Medical School, Dallas, Texas, USA
| | - Alex Najjar
- Surgery, The University of Texas Southwestern Medical Center Medical School, Dallas, Texas, USA
| | - Caroline Park
- Surgery, The University of Texas Southwestern Medical Center Medical School, Dallas, Texas, USA
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Mortman KD, Tanenbaum MT, Cavallo KM, Kelley D, Bonitto SS, Sadur A, Amdur R, Sarin S, Napolitano MA. Reintervention Rate After Pigtail Catheter Insertion Compared to Surgical Chest Tubes. Am Surg 2023; 89:5487-5491. [PMID: 36786011 DOI: 10.1177/00031348231157419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
BACKGROUND Prior studies suggest similar efficacy between large-bore chest tube (CT) placement and small-bore pigtail catheter (PC) placement for the treatment of pleural space processes. This study examined reintervention rates of CT and PC in patients with pneumothorax, hemothorax, and pleural effusion. METHODS This retrospective study examined patients from September 2015 through December 2020. Patients were identified using ICD codes for pneumothorax, hemothorax, or pleural effusion. Use of a pigtail catheter (≤14Fr) or surgical chest tube (≥20Fr) was noted. The primary outcome was overall reintervention rate within 30 days of tube insertion. Patients who died with a pleural drainage catheter in place, unrelated to complications from chest tube placement, were excluded. RESULTS There were 1032 total patients in the study: 706 CT patients and 326 PC patients. The PC group was older with more comorbidities and more likely to have effusion as the indication for pleural drainage. Patients with PC were 2.35 times more likely to have the tube replaced or repositioned (P < .0001), 1.77 times more likely to require any reintervention (P = .001) and 2.09 times more likely to remain in the hospital >14 days (P < .0001) compared to patients with CT. CONCLUSION PCs have a significantly higher reintervention rate compared to CT for the treatment of pneumothorax, hemothorax, and pleural effusion. Although PC are believed to cause less pain and tissue trauma, they do not necessarily drain the pleural space as well as CT. Decisions on which method of draining the chest should be made on a case-by-case basis.
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Affiliation(s)
- Keith D Mortman
- Department of Surgery, Division of Thoracic Surgery, The George Washington University Hospital, Washington, DC, USA
| | - Mira T Tanenbaum
- Department of Surgery, Division of Thoracic Surgery, The George Washington University Hospital, Washington, DC, USA
| | | | - Devon Kelley
- The George Washington School of Medicine and Health Sciences, Washington, DC, USA
| | - Stephano S Bonitto
- The George Washington School of Medicine and Health Sciences, Washington, DC, USA
| | - Alana Sadur
- The George Washington School of Medicine and Health Sciences, Washington, DC, USA
| | - Richard Amdur
- Department of Surgery, Division of Thoracic Surgery, The George Washington University Hospital, Washington, DC, USA
| | | | - Michael A Napolitano
- Department of Surgery, Division of Thoracic Surgery, The George Washington University Hospital, Washington, DC, USA
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Lodhia J, Suleman M, Chugulu S, Chilonga K, Msuya D. Chest tube thoracostomy: A simple life-saving procedure with potential hazardous risks. Int J Surg Case Rep 2023; 108:108416. [PMID: 37343502 PMCID: PMC10382721 DOI: 10.1016/j.ijscr.2023.108416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/06/2023] [Accepted: 06/06/2023] [Indexed: 06/23/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Chest tube thoracostomy is a simple life-saving procedure with many benefits but comes with significant potential morbidity. Potentially all intra-thoracic organs are at risk of possible injury as well as peritoneal. CASE PRESENTATION We present four patients who had chest tube thoracostomy with potential complications fortunately were managed promptly and recovered fully. CLINICAL DISCUSSION Complications related to tube thoracostomy is reported up to 25 % especially when done under emergency conditions. While the procedure is reported safe, it's associated morbidity is not well described. Additionally, clinicians are urged to follow standard operating procedures and address the potential complications with consent to their patients. CONCLUSION Chest tube thoracostomy is an invasive life-saving procedure performed across various clinical ranks and sub-specialties. It has potential life-threatening risks and complications therefore clinicians should be well trained to identify such complications and address accordingly.
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Affiliation(s)
- Jay Lodhia
- Department of General Surgery, Kilimanjaro Christian Medical Centre, P O Box 3010, Moshi, Tanzania; Kilimanjaro Christian Medical University College, Faculty of Medicine, P O Box 2240, Moshi, Tanzania.
| | - Mujaheed Suleman
- Department of General Surgery, Kilimanjaro Christian Medical Centre, P O Box 3010, Moshi, Tanzania
| | - Samwel Chugulu
- Department of General Surgery, Kilimanjaro Christian Medical Centre, P O Box 3010, Moshi, Tanzania; Kilimanjaro Christian Medical University College, Faculty of Medicine, P O Box 2240, Moshi, Tanzania
| | - Kondo Chilonga
- Department of General Surgery, Kilimanjaro Christian Medical Centre, P O Box 3010, Moshi, Tanzania; Kilimanjaro Christian Medical University College, Faculty of Medicine, P O Box 2240, Moshi, Tanzania
| | - David Msuya
- Department of General Surgery, Kilimanjaro Christian Medical Centre, P O Box 3010, Moshi, Tanzania; Kilimanjaro Christian Medical University College, Faculty of Medicine, P O Box 2240, Moshi, Tanzania
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Fitzgerald M, Allen T, Bai S, Mitra B, Chiu W, Helsloot D, Groombridge C, Mathew J, Kim Y. Pleural decompression procedural safety for traumatic pneumothorax and haemothorax: Kelly clamps versus fine artery forceps. Emerg Med Australas 2022; 34:954-958. [PMID: 35618677 PMCID: PMC9796613 DOI: 10.1111/1742-6723.14019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 04/27/2022] [Accepted: 05/06/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVE The present study aimed to determine the difference in force required to puncture simulated pleura comparing Kelly clamps to fine artery forceps. The treatment of symptomatic traumatic pneumothorax and haemothorax involves puncture of the parietal pleura to allow decompression. This is usually performed using Kelly clamps or fine artery forceps. Over-puncture pulmonary injury risk increases with the force used. METHODS An experienced single operator performed puncturing of simulated parietal pleura on a thoracic mannequin while wearing a force sensor under gloves. The force imparted at the device tip onto the parietal pleura was estimated by subtracting the force required to hold the device from the total force. Outcome variables were the total maximum force and force imparted by the device. RESULTS There were 11 simulated procedures completed, seven using Kelly clamps and four using fine artery forceps. After subtracting the force required to hold the chosen forceps, the median value of pleural puncture force using Kelly clamps was 52.91 N (IQR 36.68-63.56) and 10.70 N (IQR 7.64-26.56) using fine artery forceps (P = 0.006). CONCLUSION A significantly increased force was required to puncture simulated parietal pleura using Kelly clamps compared to fine artery forceps. This higher puncture force will be associated with increased instrument acceleration at the time of pleural puncture, which may result in an increased risk of injury to the underlying lung. Based on these data, clinicians may reduce the risk of pulmonary injury by using fine artery forceps rather than Kelly clamps when performing pleural decompression.
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Affiliation(s)
- Mark Fitzgerald
- National Trauma Research InstituteMonash UniversityMelbourneVictoriaAustralia,Trauma ServiceAlfred HealthMelbourneVictoriaAustralia
| | - Thomas Allen
- National Trauma Research InstituteMonash UniversityMelbourneVictoriaAustralia
| | - Shifeng Bai
- Department of Mechanical and Aerospace EngineeringMonash UniversityMelbourneVictoriaAustralia
| | - Biswadev Mitra
- National Trauma Research InstituteMonash UniversityMelbourneVictoriaAustralia,Emergency and Trauma CentreAlfred HealthMelbourneVictoriaAustralia
| | - Wing Chiu
- Department of Mechanical and Aerospace EngineeringMonash UniversityMelbourneVictoriaAustralia
| | | | - Chris Groombridge
- National Trauma Research InstituteMonash UniversityMelbourneVictoriaAustralia,Trauma ServiceAlfred HealthMelbourneVictoriaAustralia,Emergency and Trauma CentreAlfred HealthMelbourneVictoriaAustralia
| | - Joseph Mathew
- National Trauma Research InstituteMonash UniversityMelbourneVictoriaAustralia,Trauma ServiceAlfred HealthMelbourneVictoriaAustralia,Emergency and Trauma CentreAlfred HealthMelbourneVictoriaAustralia
| | - Yesul Kim
- National Trauma Research InstituteMonash UniversityMelbourneVictoriaAustralia
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Anderson D, Chen SA, Godoy LA, Brown LM, Cooke DT. Comprehensive Review of Chest Tube Management: A Review. JAMA Surg 2022; 157:269-274. [PMID: 35080596 DOI: 10.1001/jamasurg.2021.7050] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Thoracostomy, or chest tube placement, is used in a variety of clinical indications and can be lifesaving in certain circumstances. There have been developments and modifications to thoracostomy tubes, or chest tubes, over time, but they continue to be a staple in the thoracic surgeon's toolbox as well as adjacent specialties in medicine. This review will provide the nonexpert clinician a comprehensive understanding of the types of chest tubes, indications for their effective use, and key management details for ideal patient outcomes. Observations This review describes the types of chest tubes, indications for use, techniques for placement, common anatomical landmarks that are encountered with placement and management, and an overview of complications that may arise with tube thoracostomy. In addition, the future direction of chest tubes is explored, as well as the management of chest tubes during the COVID-19 pandemic. Conclusions and Relevance Chest tube management is subjective, but the compilation of data can inform best practices and safe application to successfully manage the pleural space and ameliorate acquired pleural space disease.
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Affiliation(s)
- Devon Anderson
- Division of General Thoracic Surgery, Department of Surgery, University of California, Davis Health, Sacramento
| | - Sarah A Chen
- Division of General Thoracic Surgery, Department of Surgery, University of California, Davis Health, Sacramento
| | - Luis A Godoy
- Division of General Thoracic Surgery, Department of Surgery, University of California, Davis Health, Sacramento
| | - Lisa M Brown
- Division of General Thoracic Surgery, Department of Surgery, University of California, Davis Health, Sacramento
| | - David T Cooke
- Division of General Thoracic Surgery, Department of Surgery, University of California, Davis Health, Sacramento
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