Jeffrey A. Claridge

Introduction

The most common indications for placement of a chest tube are pneumothorax (simple or tension), hemothorax, hemopneumothorax, empyema, and pleural effusion (acute or chronic). A chest tube needs to be placed in three defined situations. In the urgent situation the patient has unstable physiologic parameters and requires immediate chest tube placement. In the semiurgent situation the mandatory chest tube is needed “sooner rather than later,” and has an acute problem or indication but appears hemodynamically stable. However, delay in placing the chest tube could result in the patient becoming unstable and the need for an urgent procedure because of clinical deterioration. The nonurgent situation is typically elective and occurs in patients with stable hemodynamics and a chronic or recurrent physiologic problem. In other elective situations a chest tube is needed as part of a scheduled procedure, such as diaphragm repair or thoracotomy.

Superficial Anatomy and Topographic Landmarks

Regardless of the indication or urgency, five key anatomic concepts must be understood to maximize the effectiveness and safety of accessing the pleural space when placing a chest tube, as follows:

The first important concept of placing a chest tube or accessing the pleural space involves the ability to identify superficial anatomic landmarks (Fig. 43-1, A). The key landmarks for accessing the pleural space are identification of the clavicular head; midclavicular line; the anterior, middle, and posterior axillary lines; and intercostal spaces with corresponding ribs. The ability to count ribs accurately will facilitate the placement of chest tubes. In a female patient the nipple should not be used as a landmark. Instead, the inframammary fold should be used to identify the 5th rib at the anterior axillary line. In a male patient the lower border of the pectoralis major muscle is a good approximation for the site of tube insertion.

The second key concept when accessing the pleural space is to recognize that the intercostal neurovascular bundles lie just below the inferior portion of the ribs (Fig. 43-1, B). Thus it is important to place the chest tube over the most superior portion of the rib to avoid injuring the intercostal neurovascular bundle.

The third anatomic principle is to recognize the boundaries of the chest and pleural space. Failure to recognize these boundaries can result in misadventures in chest tube placement such as placing a tube into or below the diaphragm, which can cause bleeding or injury to intraabdominal or major vascular structures (Fig. 43-2, A).

The fourth critical anatomic concept is to understand the difference between the left and right chest (Fig. 43-2, B). The key differences between the left and right chest must be appreciated when accessing the pleural space. The right lung has three lobes and the left has two lobes. The location of the horizontal fissure on the right and oblique fissure on the left is at approximately the 4th rib at the anterior axillary line. Staying below this rib can help avoid placement of the tube within a fissure.

The fifth and final important anatomic detail is to understand the cross-sectional anatomy of the chest wall and the layers that must be traversed to access the chest. These layers include the skin, subcutaneous tissue, intercostal muscles, and parietal pleura (Fig. 43-2, C).

Specific Indications and Conditions

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