So you’re faced with a chest tube that “someone else” inserted, and the followup chest xray shows that the last drain hole is outside the chest. What to do?

Well, as I mentioned, there is very little written on this topic, just dogma. So here are some practical tips on avoiding or fixing this problem:

• Don’t let it happen to you! When inserting the tube, make sure that it’s done right! I don’t recommend making large skin incisions just to inspect your work. Most tubes can be inserted through a 2cm incision, but you can’t see into the depths of the wound. There are two tricks:
  • In adults with a reasonable BMI, the last hole is in when the tube markings show 12cm (bigger people need bigger numbers, though)
    
  • After insertion, get into the habit of running a finger down the radiopaque stripe on the tube all the way to the chest wall. If you don’t feel a hole (which is punched through the stripe), this will confirm that the it is inside, and that the tube actually goes into the chest. You may laugh, but I’ve seen them placed under the scapula. This even looks normal on chest xray!
• Patients with a high BMI may not need anything done. The soft tissue will probably keep the hole occluded. If there is no air leak, just watch it.
• If the tube was just put in and the wound has just been prepped and dressed, and the hole is barely outside the rib line, you might consider repositioning it a centimeter or two. Infection is a real concern, so if in doubt, go to the next step.
• Replace the tube, using a new site. Yes, it’s a nuisance and requires more anesthetic and possibly sedation, but it’s better than treating an empyema in a few days.

Related posts:

• Chest tube tips
• Troubleshooting air leaks

Yesterday I presented the problem of the malpositioned chest tube, specifically one that is not completely in the pleural space. This one is way out:

So what do the doctor books say? Well, the first thing you will discover if you try to look it up is that THERE IS NO LITERATURE ON THIS COMMON PROBLEM! There are a few papers on tubes placed in the fissure and tubes inserted into the lung parenchyma. But there are only a few mentions of tubes with holes still outside the chest.

I’ve gotten a number of comments, including “you can push them in a little”, “take it out and put in another”, and “never push them in.” Since we don’t have any science to guide us, we have to use common sense. But remember, I’ve shown you plenty of examples where something seems reasonable, but turns out to be ineffective or downright harmful.

There are three principles that guide me when I face this problem:

• Prevention is preferable to intervention
• Do no (or as little as possible) further harm
• Be creative

Tomorrow, I’ll finish this series and provide some tips and guidelines to help manage this problem using the principles outlined above.

It happens from time to time. Your patient has a hemothorax or pneumothorax and you insert a chest tube. Well done! But then the xray comes back:

The last hole in the drain is outside the chest! What to do???

Here are the questions that need to be answered:

• Pull it out, leave it, or push it in?
• Does length of time the tube has been in make a difference?
• Does BMI matter?

Leave comments below regarding what you do. Hints and final answers next!