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WATER SEAL DRAINAGE (WSD)

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WATER SEAL DRAINAGE (WSD)

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Kategori: Uncategorized

Chest tube insertion - series

Normal anatomy

Indication

Procedure

Aftercare

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Procedure:

Chest tubes are inserted to drain blood, fluid, or air and allow full expansion of the lungs. The
tube is placed in the pleural space. The area where the tube will be inserted is numbed (local
anesthesia). The patient may also be sedated. The chest tube is inserted between the ribs into the
chest and is connected to a bottle or canister that contains sterile water. Suction is attached to the
system to encourage drainage. A stitch (suture) and adhesive tape is used to keep the tube in
place.
The chest tube usually remains in place until the X-rays show that all the blood, fluid, or air has
drained from the chest and the lung has fully re-expanded. When the chest tube is no longer

needed, it can be easily removed, usually without the need for medications to sedate or numb the
patient. Medications may be used to prevent or treat infection (antibiotics).

European Course Trauma Care

THORACIC TRAUMA

EPIDEMIOLOGY
The rate of thoracic trauma in the United States is 12 per million population per day - and 20-25% of deaths due to trauma are attributed to
thoracic injury. It is estimated that thoracic trauma are responsible of approximately 16.000 deaths per year in the United States. The
incidence has increased rapidly in this century of high-speed vehicular travel. Immediate deaths are usually due to major disruption of the
heart or of great vessels. Early deaths due to thoracic trauma occurring within 30 minutes to 3 hours after the injury are secondary to cardiac
tamponade airway obstruction and aspiration.
Two thirds of these patients reach the hospital prior to die. Only 10-15% of blunt trauma require thoracic surgery, and 15-30% of the
penetrating chest trauma require open thoracotomy. 85% of patients with thoracic trauma, can be managed by simple lifesaving manoeuvre
that do not require surgical treatment.
Thoracic injury occurs in the chest wall, lungs and pleura, thoracic great. vessels, diaphragm heart, trachea, bronchus and oesophagus. The
magnitude of those problems and the significance of the associated injuries serve to underscore the importance of complete evaluation and
timely intervention in the management of thoracic trauma.
Many patients can be successfully treated with or without tube thoracostomy, respiratory support and in a few cases with emergency
thoracotomy. Endotracheal intubation support and treats post-traumatic respiratory insufficiency. Although some of the complex and
potentially fatal traumatic thoracic injuries require emergent surgical intervention, most of them can be treated nonoperatively by the proper
application of certain fundamental principles of initial trauma management. These principles can substantially reduce the morbidity and
mortality. Appropriate early management of the rapidly fatal and potentially fatal thoracic injuries can also significantly decrease the late
complications. Optimal treatment requires a through knowledge of the ethiology and pathophysiology of the thorax and expertise the
therapeutic interventions. Improved prehospital care and rapid transportation have increased the survival, but the lethality remains high.
Pathophysiology
Thoracic trauma can induce two serious derangement:
1 Respiratory insufficiency due to:
pneumothorax tension pneumothorax open pneumothorax flail chest pulmonary contusion aspiration
2. Hemorrhagic shock due to:
hemothorax hemomediastinum
Thoracic cavity is constituted from two structures: the first, rigid, comprehending the rib cage, clavicle, sternum, scapula and the second
comprehending respiratory muscles. Adequate ventilation and oxygenation depends on an intact chest wall. Significant injury with fracture

and muscular disruption may allow direct injury to the underlying lungs, heart, great vessels and upper abdominal viscera. In addition,
respiration may be seriously impaired by effective or paradoxical motion of a portion of the thoracic cage (as in flail chest) and the result is
respiratory insufficiency.
Penetrating wound of the chest (gunshot or stab wound) may cause comminuted fractures of a rib, with bone fragments driven into the lung
substance.
The most common manifestation of penetrating trauma to the visceral and parietal pleura is disruption of normal negative intrapleural
pressure resulting in pneumothorax. Penetrating wounds cause both direct injury to structures encountered by the weapon and indirect injury.
The extent of internal injuries cannot be judge by the appearance of a skin wound.
Blunt forces applied to the chest wall cause injury by three mechanisms: rapid deceleration, direct impact and compression. Rapid
deceleration is the usual force involved in high speed motor vehicle accidents and falls from height. The degree of external trauma may not
fully predict the severity of internal injuries and clinical suspicion of cardiac and vascular trauma should be heightened.
Direct impact by a blunt object can cause localised fractures of the ribs, sternum or scapula with underlying lung parenchyma injury, cardiac
contusion or pneumothorax.
Compression of the chest by a very heavy object, which prevents respiration and causes marked increases in blood pressure within veins of
the upper thorax, may result in traumatic asphyxia. Anterior-posterior compression forces place indirect pressure on the ribs, causing lateral,
mid-shaft fractures. Lateral compression forces applied to the shoulder are common causes of sternoclavicular joint dislocation and clavicle
fractures. Massive blunt injury to the chest wall may comprise elements of deceleration, direct impact, and compression to yield multiple
adjacent rib fractures is in more than one location. In this setting, a free-floating segment of the chest wall can more paradoxically with
respiration causing ineffective ventilation.
Moreover than respiratory insufficiency thorax trauma can cause hemorrhagic shock due to hemothorax and rarely to hemomediastinum.
Hemothorax is common in both penetrating and non-penetrating injures to the chest. If the hemorrhage is severe, it may not only cause
hypovolemic shock but also dangerously reduces vital capacity by compressing the lung on the involved side. Persistent hemorrhage usually
arises from an intercostal or internal thoracic (internal mammary) artery and less frequently from the major hylar vessels. Bleeding from the
lung generally stops within a few minutes, although initially it may be profuse. In some cases hemothorax may come from a wound of the
heart or from abdominal structures such as the liver or spleen if the diaphragm has been lacerated. Hypovolemic shock and
hemomediastinum can derive from a thoracic great vessels injury that may be result of penetrating or blunt trauma. The most common
etiology is penetrating trauma; however, the descending thoracic aorta, the innominate artery, the pulmonary veins, and the vena cavae are
susceptible to rupture for blunt trauma.
Goal of the chapter
At the end of this chapter the student must be able to identify and treat the chest trauma and to understand and avoid the most common
mistakes and complications in the treatment. The initial management of the patients with thoracic trauma is frequently the responsibility of the
emergency physician who is not a thoracic surgeon but a general surgeon. It is therefore imperative that emergency physician is able to
recognise the thoracic injuries that are or will be dramatic if not treated properly.
In unstable and critical circumstances, quick decisions and adequate manoeuvres based on recordings of vital signs and a right
interpretation of clinical and diagnostic pattern are required.
The purpose of this chapter is to establish the right guidelines in the treatment of thoracic injuries.
Thoracic injury: priorities
The evaluation of the patient's chest trauma is only a part of the total assessment; furthermore because thoracic injuries are severe and
potentially lethal, the diagnosis and therapy go hand in hand.
In unstable and critical patients quick decisions based on check of the following vital signs are required.
Airway patency: in the initial survey is mandatory to control the airway patency.
The airway can be occluded by foreign bodies present in the month or by a fall of the tongue backwards as occurs in unconscious patients.
Patency of the airway must be retarded by a simple manoeuvre to remove foreign body from the month or to correct backwards fall of the
tongue (Chap. AIRWAY AND VENTILATION).
All the airway manipulations must be performed with respect to potential cervical spinal injuries.
Breathing: in order to know if patient is breathing is necessary to check respiratory movement, and their extension.
Remember that cyanosis appears very late in hypoxia due to a thoracic trauma because in shocky patients the skin blood flaw depends on
blood redistribution in the body.
Circulation: the state of the circulation is evaluated by ossessing patient's pulses (radial, carotideal or femoral).
The blood pressure is evaluated by width of pulse. In hypovolemic shock radial pulse becomes small; may be absent when blood pressure is
below 60 mm/Hg. In thoracic trauma is important to control the neck veins that are flat in hypodermia; are distended when there is cardiac
tamponade. But if cardiac tamponade is associated with hypovolemic shock distension of the neck veins may be absent.
In thoracic trauma patients there are the following life-threatening lesions that must immediately identified and treated.
Open pneumothorax: usually results from a penetration wound of the chest that may create a communication between the pleural space
and external environment. As the size of this defect approaches two thirds the size of the tracheal diameter, air passes preferentially through
the lower resistance injury tract rather than through the normal airways. This severely compromises oxygenation and ventilation and is
immediately life-threating. In an open or "sucking" wound of the chest wall, the lung on the affected side is exposed to atmospheric pressure,

which results in the lung's collapse and a shift of the mediastinum to the uninvolved side. Because of the severe degree of venoarterial
shunting that occurs in both lungs, resulting in profound ventilation-perfusion inequality, the patient becomes cyanotic and has serious
respiratory distress.
The open pneumothorax must be treated rapidly using one of two approaches. In the spontaneously ventilating patient, application of a
sterile occlusive dressing with vaseline gauze large enough to cover the wound entirely taped securely on three sides is the treatment of
choice. Tube thoracotomy at a remote site should be placed.
If the chest wall defect is relatively small, the pleura may soon seal and no further intervention is necessary. A second approach is to simply
intubate the patient and initiate positive pressure ventilation.
Often surgical repair is required.
Tension pneumothorax: develops when air enters the pleural space but cannot exit. The consequence is progressively increasing
intrathoracic pressure in the affected hemithorax resulting in impaired central venous return and mediastinal shift.
Air enters pleural cavity through lung wound or ruptured bleb (or occasionally via penetrating chest wound) with valvelike opening. Ipsilateral
lung collapse and mediastinum shifts to opposite side compressing controlateral lung and impairing its ventilating capacity. Clinically, the
patient experiences dyspnea, complains of chest pains, and becomes cyanotic because of shunting in the collapse of lung and has
hemodynamic instability because decrease is venous return for endopleural hypertension. The presence of hyperresonance and the absence
of breath sounds, together with X-ray examination, should be useful in confirming the cause of the emergency.
A chest X-ray film indicates that the trachea and mediastinum are deviated to the side opposite the tension pneumothorax, while on the
ipsilateral side intercostal spaces are widened and the diaphragm is pushed downward. The emergency require immediate thoracostomy
with underwater-seal drainage. If the lung does not fully re-expand after tube thoracostomy and there is a large ongoing air leak the airways
should be evaluated bronchoscopically to exclude a major injury. However, in most cases, no further treatment for tension pneumothorax will
be required after chest tube insertion.
Massive hemothorax: is common in both penetrating and blunt chest injuries. Patients who sustain acute hemothorax are at risk for
hemodynamic instability due to loss of intravascular volume and compromised central venous return due to increased intrathoracic pressure.
Lung compression due to massive blood accumulation may also cause respiratory compromise. Sources of hemothorax are: lung, intercostal
vessels, internal mammary artery, thoracicoacromial artery, lateral thoracic artery, mediastinal great vessels, heart, abdominal structures
(liver, spleen) when diaphragmatic hernia.
The diagnosis is readily made from the clinical picture and X-ray evidence of fluid in the pleural space. Primary thoracentesis is carried out to
confirm the diagnosis. Optimal therapy consists of the placement of a large (36 French) chest tube. A moderate size hemothorax (500-1500
ml) that stops bleeding after thoracostomy can generally be treated by closed drainage alone. However, a hemothorax of greater than 1500
to 2000 ml as with continued bleeding of more than 100 to 200 ml per hour is an indication for emergency thoracotomy or thoracoscopy.
A small percentage of hemothoraces proceed to clot and cannot be evacuated by thoracentesis. Massive clots may lead to respiratory
difficulty and infection, and should be evacuated surgically. Small clots will probably be resorbed and do not require operative removal.
Cardiac tamponade: penetrating cardiac injuries are a leading cause of traumatic death in urban areas and are generally more severe than
blunt injuries. Patients with penetrating wounds of the heart can be classified in 3 general groups:
1. patients who have received extensive lacerations or large-calibre gunshot wounds, that die almost immediately, as a result of rapid and
voluminous blood loss;
2. patient with small wounds of the heart, caused by ice picks, knives or other small agents who because of the development of cardiac
tamponade, reach the hospital alive. Cardiac tamponade, by bringing pressure to bear on the bleeding heart wall, also plays an important
role in controlling the hemorrhage;
3. patient with associated serious injuries in the chest and/or elsewhere in the body which, in themselves, may contribute to death.
The condition of the patient, when he is admitted to the hospital, must not be used as an index of the severity of the injury. There are
moribund patients with no blood pressure and nonperceptible pulse, who survive operation and recover; on the other hand there are patients
in fair condition, with a systolic blood pressure ranging from 70 mmHg to normal and fair-to-good pulse, who die before surgery. The
immediate cause of death is either exanguination, cardiac tamponade or interference with the conduction mechanism.
Diagnosis generally is easy if the physician maintains a high degree of suspicion of heart injury in every chest wound he encounters. The
safest approach is to remove the patient's clothing and survey the entire body surface quickly for evidence of multiple injuries. Auscultation of
the thorax is performed specifically to evaluate the clarity of heart tones and breath sounds. Muffled heart tones are an indication of blood in
the pericardium. A systolic - to diastolic gradient of less then 30 mmHg, associated with hypotension is consistent with cardiac tamponade.
Neck veins are distended. Central venous pressure is elevated. The X-ray film may demonstrate a widening of the cardiac silhouette. The
ultrasound scan shows presence of blood in pericardial space. Electrocardiograph is not particularly helpful. Prompt definitive therapy is
imperative. This includes antishock therapy, pericardiocentesis (possibly under U.S. guide), emergency thoracotomy and suture of the
wound.
The following lesions are life-threatening but give to the physician more time to diagnose and treat them.

Thoracic cage injuries: with severe trauma, fractures of any rib or combination of ribs and fractures in this area are likely. However, the
fracture usually occurs at the point of impact, often laterally such fractures are hard to see on X-ray films. Crushing injuries may produce
multiple eggshell fractures, the sites being dependent on the direction of the compressing forces. For example, impaling the anterior chest on
a steering wheel as in an automobile accident, often fractures the sternum and several ribs anteriorly on both sides. Besides rib fractures,
costovertebral dislocation may occur at any level, as may occur costochondral and chondrosternal separations.
Fractures may be transverse or oblique and the fragments may override or a pointed fragment may be pushed inward, tearing the pleura and
underlying lung.
In the elderly patient with atrophic, decalcified ribs, fractures may result from simple trauma, coughing or any severe muscle pull. Fractures of
the rib or sternum or costovertebral separations are diagnosed from movement of fragments, ecchymosis and crepitus, as well as by X-ray
examination. Since pain characteristically occurs with inspiration, the patient tends to splint the chest wall and therefore, hypoventilates.
A chest X-ray film must be performed, not only to identify the number and the extent of rib fractures, but also to determine whether there is an
associated pneumothorax, hemothorax and pleural effusion. Rib fractures usually heal readily if complications are handled properly.
However, the pain associated with the fracture can prevent proper ventilation and coughing, leading to atelectasis, retained secretions and
pneumonia, especially in the elderly. Damage to the underlying lung may cause hemothorax, pneumothorax or pulmonary contusion, multiple
rib fractures may produce paradoxical movement of the chest wall, with a flail segment. Pain from a rib fracture can be treated by intercostal
or paravertebral block; this promptly relieves the pain and quiets the laboured respiration which may be accentuating paradoxical motion of
the chest. The major problem with a block are increased reflex bronchial secretions; these must be removed if patients are to avoid an
obstructive type of pneumonia which is particularly dangerous in the elderly.
If coughing is inadequate, tracheal aspiration on by catheter or by broncoscopy and occasionally by endotracheal intubation may be
necessary.
The ribs usually become fairly stable within 10 days to two weeks. Firm healing with callus formation is seen after about six weeks.
Flail chest: A segment of chest wall does not have continuity with the rest of thoracic cage because multiple risk fractures causing serious
respiratory distress.
In flail chest injury, the unstable segment wall moves separately and in ,an opposite direction from the rest of the thoracic cage during the
respiration cycle. In politrauma patients flail chest injury is quite common. Thirty-one percent of 50.000 trauma patients included in the Major
Trauma Outcome study had chest injuries. Five percent of these patients had flail chest injury.
Flail chest injury usually results from direct impact. If the crushing force is from the lateral direction, the injury usually consists of fractures in
at least two sites in multiple adjacent ribs on the involved side, resulting in a "floating" central portion of the chest wall, which goes in and out
with respiration in a reverse or paradoxical manner to the rest of the chest wall. This type of respiration markedly decreases the efficiency of
ventilation, and is usually accompanied by severe pain that makes the coughing mechanism ineffectual.
If the crushing blow is directly over the sternum, as often happens in steering wheel injuries, fractures of the sternum may occur. Such an
injury is most frequently associated with bilateral costochondral fractures usually from the first rib down resulting in extreme flailing of the
anterior portion of the chest wall.
The physiopathologic effects of flail chest are an important decrease in vital capacity, reduction in functional residual capacity. Often there are
ventilation-perfusion imbalance, hypoxemia, decreased compliance, increased airway resistance and increased breathing effort. The
diagnosis of flail chest injury is made by physical examination. adequate examination after blunt chest trauma must include inspection of an
unclothed patient from anterior, posterior and both lateral angles. Clinically, the unsupported portion of the chest wall is seen to move
paradoxically with respiration. On inspiration, the flail area moves in; on expiration or coughing it moves outward. If the flail segment is large,
the important effect are those of inadequate ventilation, inadequate perfusion resulting in progressive hypoxia and hypercapnia and
inefficient coughing with retained secretions, radiographs can document multiple rib fractures. The treatment of flail chest involves selective
use of endotracheal intubation and mechanical ventilation. Not all patients require intubation. Flail chest patient without respiratory
impairment generally do well without ventilatory assistance. The primary indication for endotracheal intubation and mechanical ventilation is
respiratory decompensation. Aggressive pulmonary physiotherapy with suctioning, incentive spirometry, early mobilisation, and umidification
of air is appropriate for all patients. Intermittent positive pressure breathing, postural drainage, cupping or clapping and therapeutic fiberoptic
broncoscopy to suction retained secretions and treat atelectasis are often necessary.
Further than internal fixation effected by endotracheal tube or tracheostomy the stabilisation of the chest wall may be performed by external
surgical fixation.
Pneumothorax: lung laceration or bronchial lesion permit air entry into pleural space. That results in collapse of the lung, increase of
endopleural pressure and compression of controlateral lung by mediastinum dislocation. In this case a severe alteration of ventilation
perfusion ratio may occur because blood circulation in non ventilated pulmonary area. Chest percussion in patient with pneumothorax shows
hyperresonance and breath-sounds decrease or absence confirmation of the diagnosis is obtained by chest X-ray.
In the absence; of hemodynamic compromise, even large pneumothoraces rarely require emergent management. However, any posttraumatic pneumothorax should be treated as expeditiously as possible. A chest tube is inserted after cardiologic evaluation and lung
reexpansion carefully and repeatedly assessed with follow-up chest X-rays. Placement of an intercostal tube or catheter can be readily
accomplished under local or intercostal nerve block anaesthesia, or both.
It may be done at the bedside, but strict aseptic precautions need to be observed. The site for tube insertion should be one that is away from
adherent lung. Generally preferred is the second or third anterior intercostal space in the midclavicular line or the fourth or fifth intercostal
space in the midaxillary line. To help select the optimal point of entry, chest X-ray films should be reviewed unless the clinical situation is an
of extreme urgency.
Pulmonary contusion: is of primary importance in the field of major trauma to the chest. It is a potential life-threatening condition mainly
because the onset of symptoms is insidious.

Also, since the force required to produce a lung contusion must be great, the lesion is likely to occurs principally in cases of high speed
accidents, falls from great heights and injuries by high-velocity bullets.
Patients suffering such accidents often have so many other obvious injuries that detection of a chest lesion may escape. After seemingly
negligible initial signs and symptoms, the outcome may be fatal. Symptoms and signs of pulmonary contusion are: dispnea, hypoxemia,
cyanosis, tachycardia, rare or absent breath sounds, rib fractures.
Hemorrhage, oedema and microatelectasis are the morphologic consequences of pulmonary contusion. A prompt diagnosis is the main
factor in initiating management and determining whether treatment will be effective. The diagnosis is first suspected from history of major
trauma.
The chest X-ray film is very important, and may show patchy, undefined densities or homogenous consolidation. Patients who sustain
pulmonary contusion have to be treated with intubation, mechanical ventilatory support and antibiotic therapy chest CAT scan permits to
evaluate exactly the extension of pulmonary contusion
Rupture of trachea or major bronchi: the trachea and major bronchi because of their similar anatomic position are subject to the same
mechanisms of injury for either blunt or penetrating trauma. Rupture of the trachea or major bronchi is usually secondary to an injury of the
chest as a result of an automobile accident. It is a serious injury with an estimated mortality of 30%. More than 80% of the ruptures of bronchi
are within 2.5 cm of the carina. Injuries to the main bronchi and intrathoracic trachea are more prevalent than those to the cervical trachea
because the latter is protected by the mandible and sternum anteriorly and by vertebrae posteriorly. The intimate anatomical relationship of
the trachea to the great vessels, lungs and heart explain the high incidence of serious associated injuries in blunt and penetrating trauma.
The clinical picture appears in two patterns, depending on whether or not there is free communication between the rupture of the tracheabronchial tree and the pleural cavity. If there is free communication, a large pneumothorax results. The usual signs of tracheobronchial
disruption are the followings:
hemoptysis dyspnea subcutaneous and mediastinal emphysema occasionally cyanosis.
Tube thoracostomy shows continuos bubbling of air in the water seal, and suction fails to reexpand the lung. The chest X-ray demonstrate
pneumothorax, pleural effusion, pneumomediastinum or subcutaneous air. Overall 90% of these patients will have an abnormal chest X-ray
on admission.
Bronchoscopy should be carried out promptly when tracheobronchial rupture is suspected, since it is the most reliable means of establishing
the diagnosis.
The bronchoscopy has a role not only in diagnosis of tracheobronchial disruption, but also may be an invaluable tool in resuscitation.
Tracheal and selective bronchial intubation may allow ventilation of the intact lung while is performed on the controlateral bronchial rupture.
Bronchoscopy should be carried out promptly; if it indicates that the bronchial tear involves less than one-third of the lumen, the patient is
stable and if the thoracostomy tube under-water-seal drainage results in complete expansion of the lung, treatment may be conservative.
However in all other types of tracheobronchial injury, thoracotomy should be performed as soon as possible.
In this situation, ventilatory support with high frequency ventilation has not been shown to be useful, whereas success has followed the use
of double lumen tubes and selective bronchial intubation followed by early surgical repair, with mucosal - to - mucosal closure with
interrupted sutures.
Heart injuries (cardiac contusion): myocardial contusion is associated, in chest blunt trauma, with fractures of the sternum or ribs.
The diagnosis is based on electrocardiogram abnormalities and elevation of serial cardiac enzymes.
Cardiac contusion can simulate a frank myocardial infarction. Electrocardiographic findings are multiple, premature ventricular contractions,
atrial fibrillation, right branch block and changes in ST.
Patient must be submitted to observation with cardiac monitoring.
Thoracic great vessels injuries: is principally a civilian phenomenon an currently accounts of 8-9% of vascular injuries seen in trauma
centers. It may be result of penetrating or blunt trauma.
The patient with chest trauma may present with respiratory distress due to hemothorax. An initial "rush" of a large volume of blood after tube
thoracostomy may indicate great vessels injury. The classic signs of pericardial tamponade may be present. Suggestive radiological signs
include presence of hemothorax, pneumothorax or the foreign bodies, widening of the superior mediastinum more than 8 cm and depression
of the left mainstem bronchus more than 140 degrees.
Aortography should be performed in the patient with moderate to severe injuries that is stable hemodynamics. CAT and MR have not been
shown to be as diagnostic as aortography.
The patient with signs of respiratory distress and suspected pneumothorax should undergo immediate tube thoracostomy. As mentioned
above, if blood loss is greater than 1 L, with continued bleeding must be performed a thoracotomy and repair of the rupture of the vessel.
Trauma to oesophagus: in trauma patients rupture of oesophagus is very rare. More frequent is the perforation of the oesophagus for
penetrating trauma. Oesophagus trauma is lethal if unrecognised because mediastinitis due to contamination mediastinal space by
oesophageal content with very high concentration of necrosis bacteria. The patient's complain of sudden excruciating pain in the epigastrium,
which lasts and radiates to the chest, to the back or both. Dyspnea, cyanosis and shock soon set in and dominate the clinical picture.
Emphysema and pneumo - or hydropneumothorax, especially in the left mediastinum develop and become visible radiologically.
Esophagogram may be performed when the patient is stable.
Esophagoscopic visualisation of localised blood in the oesophagus or an actual laceration is diagnostic.
Operation is advocated when the patient is unstable and when are present major injuries.

The principles in the management of major oesophageal injuries are those of early operation, two - layer surgical closure when possible and
wide mediastinal drainage.
Extensive tissue destruction or associated major mediastinal contamination, such as occurs when repair is delayed by more than 12-16
hours, are indications to consider a closure with a T-tube or an exclusion technique.
Diaphragmatic injuries: once relatively uncommon, injuries of the diaphragm are occurring more frequently, paralleling the rise of frequency
of automobile accidents. The diagnosis is often missed because of associated intraabdominal injuries. Diaphragmatic injuries may also be
caused by penetrating or blunt trauma. Diaphragmatic injury is suspected in any penetrating thoracic wound (gunshot, stab or accidental
perforation) at or below 4th intercostal space anteriorly, 6th interspace laterally, or 8th interspace posteriorly, although sharply oblique
wounds or missiles deflected by ribs may also penetrate diaphragm. Stomach and other abdominal viscera may herniate into left thorax; left
lung may collapse, right lung may be compressed, mediastinum my be shifted and trachea deviated to the right.
Symptoms are related to the quantity of herniated viscera in to the thorax. The usual clinical manifestations are: dyspnea, chest or shoulder
pain and cyanosis. If the herniated organ is stomach, the dyspnea can be relieved dramatically by introduction of a nasogastric tube. The
diagnosis is performed or suspected by chest X-ray that may demonstrate: atelectasis with silhouetting of the ipsilateral diaphragm, evidence
of an air-filled or soled viscus in the thorax and abnormal curvilinear shadow above the diaphragm. A contrast stomach X-ray may visualise
the stomach herniated into thorax. Ultrasound and CAT scan will confirm the diagnosis.
The most common errors in diaphragmatic trauma are failure to inspect the leaflets adequately during operative exploration or penetrating
injury and failure to suspect the possibility of diaphragmatic injury.
The treatment is always surgery by an abdominal approach.
The decision to repair an isolated diaphragmatic rupture in an acutely injured patient should depend on how the patient tolerates the loss of
normal, negative intrathoracic pressure.
Gross signs of cardiorespiratory distress or shock are indication for immediate repair.
Thoracic aorta rupture: rupture of the thoracic aorta is a common cause of sudden death in roctures of unrestrained frontal collision and in
a fall from a great height.
Laceration of the thoracic aorta supervenes near the aortic legamentum arteriosum.
If the aorta is non completely interrupted and there is an intact adventitial layer it is possible to operate on the patient and to repair the lesion.
If the patient is not diagnosed and not adequately treated will die in few hours or days.
The dynamic of the collision, fractures of the scapula, the first and second ribs and the medial third of the clavicle, all suggest severe trauma
and should lead to a suspicion of a laceration of the thoracic aorta.
The chest X-ray can show a widening of mediastinum, right tracheal shift, elevation and rightward shift of the right bronchus, depression of
the left bronchus, aortic knob outline, deviation of the oesophagus to the right,. Transesophageal U.S. scan is a useful diagnostic tool if
available. CAT scan is mandatory as well as aortography. The treatment is immediate surgery by qualified surgeon.

2005 Medical management of pneumothorax

Useful Resources - Pleural Diseases

Drs Samuel Lee and Johnny WM Chan, Department of Medicine, Queen

Elizabeth Hospital
The management of pneumothorax can broadly include the removal of air from the
pleural cavity and the prevention of recurrence in indicated patients.
Factors to consider on the management options to relieve a pneumothorax
These include the type and size of pneumothorax as well as the clinical condition
and symptoms of the patient.
1. Type of pneumothorax
Primary spontaneous pneumothorax (PSP), in the absence of underlying lung

diseases, can be managed by more conservative measures such as observation or

simple aspiration. For secondary spontaneous pneumothorax (SSP), hospital
admission with close observation and oxygen supplement should usually be
required, with a view to immediate drainage relief if necessary. A more conservative
approach is usually adopted for asymptomatic iatrogenic pneumothorax.
2. Size of pneumothorax
Larger pneumothoraces would normally be an indication for intercostal tube
drainage. In BTS guidelines, a rim between the lung margin and chest wall of 2cm
was used as a cut-off point1 while in the ACCP guidelines, the apex-to-cupola
distance of 3cm was employed instead.2
3. Clinical conditions and symptoms
Intercostal tube drainage should in general be considered for symptomatic or
clinically unstable patients. In ACCP guideline,2 the presence of the following signs
signifies clinical instability: respiratory rate >24 per minute, heart rate <60 or >120
per minute, abnormal blood pressure, SaO2 at room air <90% and the inability to
complete a full sentence. Moreover, signs of tension pneumothorax have to be
looked out, namely the deviation of trachea and mediastinum to the contralateral
side and rapid development of respiratory failure.

Management Options to relieve pneumothorax

1. Simple observation
Simple observation can be considered in patients with small primary
pneumothoraces with minimal symptoms. It has been estimated that 1.25% of the
volume of the hemithorax could be absorbed each 24 hours.3 In contrast to stable
asymptomatic patients with PSP, observation must be adopted with caution in SSP
patients, and hospital admission should be advised. High flow oxygen should be
given, though with caution in patients with COPD, to hasten the re-expansion
process.
2. Simple aspiration
Simple aspiration was proposed as the first-line intervention of all symptomatic
(and/or > 2cm size) PSP and even for selected cases of SSP in the BTS guidelines,
though it is not recommended in the ACCP guidelines. Owing to the relatively high
failure rates, only asymptomatic SSP patients with age under 50 and a rim small
than 2 cm would be considered for aspiration in BTS guidelines. Randomized
controlled studies revealed similar efficacies, less pain and shorter hospital stays
when compared to intercostal tube drainage.4-8 In Hong Kong, local unpublished
preliminary data revealed that, except in Emergency Departments,9-10 simple
aspiration has not been commonly performed. Nevertheless, it can be considered in
iatrogenic pneumothoraces. The use of new pneumothorax kits like CASP catheter

system using Seldinger technique, with or without the use of 1-way valve like
Helmlich valve, might improve the popularity of the technique in the future.
3. Chest tubes
Chest tubes still appear to be the commonest method to treat the symptomatic
pneumothoraces. In both BTS and ACCP guidelines, the use of small bore catheters
(<20F) is advocated in most stable cases, which is easier to insert and cause less
pain and complications, especially in patients of smaller build. However, in patients
on mechanical ventilation or those with suspected big broncho-pleural fistulas such
as post-operative stump dehiscence, bigger drains should be considered to cater for
the larger leaks.14 The following Drainage systems are usually being used:
a. One- bottle system
Drainage depends on gravity, with the drain connected to a tube submerged in
around 2 cm of water that provides under-water seal. This is good enough in simple
cases where suction is not required.
b. Two-bottle system
When there is concomitant drainage of fluid, the water-seal level will be elevated,
creating greater resistance. Adding a container bottle before the water-seal bottle
might solve the problem. Another form of 2-bottle system involves a water-seal
bottle connected to a second suction-regulating bottle to gauge the pressure
created via external (e.g. wall) suction.
c. Three-bottle water seal system
A suction regulating bottle is added to the two-bottle system to accommodate the
simultaneous drainage of air and fluid. The water column in the bottle will reflect
the suction generated via an external source. Handy units serving the same
function and design are commercially available.
d. One-way valve systems
This is a relatively costly option in facilitating transfer or discharge for stable cases,
preferably for use in those without significant leakages of the pneumothorax as the
presence of leakage can not be monitored easily.

Application of Suction
1. Indications
- persistent lung collapse and/or persistent air leakage
- removal of co-existing fluid, like blood or pus
2. Timing and amount of suction to be applied

- immediate suction after drainage is usually not necessary and might produce
complications like reperfusion pulmonary oedema
- can be applied after 48 hours if re-expansion is suboptimal. Drainage with 10-20
cmH2O is recommended in ordinary situations.1

3. Common methods in applying and monitoring of suction

(a) Via a suction monitoring bottle in a 2- or 3-bottle system
The suction force is measured by the height of water column in the bottle. Though
technically simple and economical, this is bulky and much vigilance is necessary for
monitoring. Moreover, the amount of suction measured and hence applied is limited
by the size of the bottles, with an upper limit of about 10cmH2O only for the
relatively small bottles in our institution. Commercially available integrated units
operating on the same concept can provide equivalent but more expensive
alternatives.
(b) Via continuous vacuum regulators
Negative pressure being directly applied from the wall suction and only the
underwater seal bottle is necessary. These can provide a more precise control even
at the low suction range (0-5kPa), which otherwise would be only a rough
estimate from the usual adjustment available in the wards. Its small size and wide
range of suction that can be applied are the major advantages. However, it is more
expensive.
(c) Via Gomco system
Combining the pump and the water bottles into a single system. It is convenient and
does not need additional source of wall suction. The maximum suction provided is
up to 25 cm H2O. However, it is bulky and the suction provided is only intermittent,
which might occasionally not be desirable in management of pneumothroax.
Moreover, the price per unit is even higher than the vacuum regulator at the time of
writing.
Clamping of the chest drain
Although being a controversial issue with no evidence to demonstrate its
usefulness,11 clamping of chest drains is not absolutely contraindicated in both BTS
and ACCP guidelines. However, chest drains should only be clamped with much
caution and is contraindicated with persistent air leakage. Presence of experienced
nursing staff, together with close monitoring of oxygen saturation and clinical
condition would be necessary.1 With clinical deterioration such as increasing
dyspnoea or oxygen desaturation, the clamp should be opened immediately.

Prevention of Recurrence: medical pleurodesis

According to international guidelines1, medical pleurodesis is reserved for those
who are too frail or unwilling to undergo surgical pleurodesis, which provides a more
definitive prevention of recurrence. Tetracycline group such as doxycline and
minocycline is the commonest agents employed with an overall efficacy about 70%
and is recommended by BTS guidelines as the first-line agents of choice1. Talc is
also widely used with its higher reported efficacy (about 90%) and lower cost. Both
agents are associated with pain and fever, but more severe complications such as
respiratory failure and ARDS had been associated with the use of talc.12-13 The use
of mixed talc with smaller particles had been suggested to the cause of these
severe systemic reactions.12
Referral to surgeons
Apart from presence of persistent air-leak or failure of re-expansion of more than 5-7
days, when there is the occurrence of a second ipsilateral or a first contralateral
pneumothorax, surgical evaluation might be necessary.1 A first occurrence of SSP
has also been indicated for pleurodesis, in contrast to PSP.2 The profession (such as
divers or pilots) and choice of patients should also be taken into consideration.1-2
References:
1. British Thoracic Society Standards of Care Committee. BTS guidelines for the
management of spontaneous pneumothorax. Thorax 2003;58(Suppl II):ii39-ii52
2. ACCP Pneumothorax Consensus Group. Management of Spontaneous
Pneumothorax. ACCP Delphi Consensus Statement. Chest 2001;119:590-602
3. Kirchen LT Jr, Swartzel RL. Spontaneous pneumothorax and its treatment. JAMA
1954;155:24-29
3. Archer GJ, Hamilton AAD, Upadhyag R, et al. Results of simple aspiration of
pneumothoraces. Br J Dis Chest 1985;79:177-182
4. Noppen M, Alexander P, Driesen P, et al. Manual aspiration versus chest tube
drainage in first episodes of primary spontaneous pneumothorax. A multicenter,
prospective, randomized pilot study. Am J Respir Crit Care Med 2002; 165: 12401244.
5. Spencer-Jones J. A place for aspiration in the treatment of spontaneous
pneumothorax. Thorax1985;40:66-67
6. Andrivert P, Djedaim K, Teboul J-L et al. Spontaneous pneumothorax: comparison
of thoracic drainage vs immediate or delayed needle aspiration. Chest 1995;
108:335-340
7. Harvey J, Prescott RJ. Simple aspiration versus intercostals tube drainage for
spontaneous pneumothorax in patients with normal lungs. BMJ 1994;309:1338-1339
8. Chan SS, Lam PK. Simple aspiration as initial treatment for primary spontaneous

pneumothorax; results of 91 consecutive cases. Journal of Emergency

Med.2004;28:133-138
9. Siu AY, Chung CH. A case series of using aspiration catheter for the management
of spontaneous pneumothorax. Hong Kong J Emerg Med 2003;10:233-237
10. So SY, Yu DY. Catheter drainage of spontaneous pneumothorax suction or no
suction, early or late removal? Thorax 1982;37:46-48
11. Rinadlo JE, Owens GR, Roger RM. Adult Respiratory Distress syndrome following
instillation of talc. J Thorac Cardiovasc Surg 1983:;85:523-526
12. Kenndy L, Rush VW, Strange C et al. Pleurodesis using talc slurry.
Chest1994;106:342-346
13. Baumann MH. What size chest tube? What drainage system is ideal? And other
chest tube management questions. Curr Opin Pulm Med 2003; 9: 276-281
Last Updated on Monday, 27 July 2009 23:45