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Hazards of tube thoracostomy in patients on a ventilator
© Shaikhrezai and Zamvar; licensee BioMed Central Ltd. 2011
Received: 14 December 2010
Accepted: 29 March 2011
Published: 29 March 2011
A patient with post-pneumonia empyema complicated by type-2 respiratory failure required mechanical ventilation as part of his therapy. A pneumothorax was noted on his chest radiograph. This was treated with an intercostal chest drain (ICD). Unfortunately, he was still hypoxic, his subcutaneous emphysema was worsening and the ICD was bubbling. A computed tomography (CT) scan of chest demonstrated that the ICD has penetrated the right upper lobe parenchyma. A new ICD was inserted and the previous one was removed. Although both hypoxia and subcutaneous emphysema improved, the patient chronically remained on mechanical ventilation.
Tube thoracostomy is a common procedure to drain fluids and/or air from the pleural space via an ICD. The British Thoracic Society (BTS) has published a guideline  for ICD insertion which in many institutions has been deployed as a standard approach to tube thoracostomy in both practice and training programs. Recently there is an increasing concern regarding the training of doctors with regard to precise and methodological ICD insertion [2, 3]. Harris et al  conducted a national survey among chest physicians in the UK recording their experiences regarding complications and serious harms following ICD insertion. The study revealed 67% of NHS trusts have experienced major complications of ICD insertion.
A new ICD was inserted with the same technique whilst the ventilator was briefly disconnected. When it was proved that the new ICD is in the appropriate position with a characteristic swing of column of water, the previous ICD was removed.
Although following the new ICD both hypoxia and subcutaneous emphysema improved the patient was chronically remained on ventilation.
Previously the risks of ICD insertion in patients on mechanical ventilation has been described  however we presented the above case due to frequent referral of patients on mechanical ventilation to us with harmful complications of tube thoracostomy. Prior to ICD insertion in a patient on mechanical ventilation, the PEEP must be turned off and the ventilator must be disconnected briefly during the introduction of the ICD. In ICD insertion deploying Seldinger technique the same steps need to be taken for introducing the guide wire as well as the chest tube. Any ICD breaching the lung parenchyma should be removed after insertion of another ICD in the pleural space.
We believe the BTS guidelines  require a new revision with the view to including the mechanical ventilation as a hazardous clinical setting in "pre-drainage risk assessment" section. Furthermore ICD insertion needs to be explained separately in self- and mechanical-ventilating patients along with considering the clinical settings as well as the specialty demands.
For instance efficient drainage of left-sided pleural effusion in a post-CABG (coronary artery bypass graft surgery) patient requires a tube thoracostomy below the triangle of safety; or fine bore ICD insertion under Seldinger technique for the treatment of pneumothorax is a well established procedure deployed by respiratory physicians while in thoracic surgery a large bore ICD with conventional insertion technique is favourable.
The royal college of surgeons has introduced S-DOPS (direct observation of procedural skills in surgery) via intercollegiate surgical curriculum programme (ISCP) . We recommend a unified usage of surgical DOPS in all specialties to sign off junior doctors' competency in tube thoracostomy in self- and mechanical-ventilating patients.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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