Tube Thoracostomy and Pleural Catheters: A Review for Emergency Clinicians

Background: Pleural cavity decompression with surgical tube thoracostomy or placement of a pleural catheter is an integral component of therapy for air or fluid within the pleural cavity and a core skill in emergency medicine. Objective: This narrative review provides a focused review of tube thoracostomy and pleural catheter placement in the emergency department. Discussion: Surgical tube thoracostomy or pleural catheter placement is performed to remove air or fluid from the pleural cavity and can be a life-saving procedure with no absolute contraindications. There are a variety of options for air or fluid removal, including standard surgical tube thoracostomy or pleural catheter placement. Literature suggests either technique may be used for pneumothorax or drainage of pleural fluid. The optimal location is at or above the fifth intercostal space in the anterior axillary or midaxillary line. Ultrasound may assist in optimizing tube placement. Surgical tube thoracostomy includes incision into the skin and subcutaneous tissue, blunt dissection into the pleural cavity, and placement of a thoracostomy tube. Pleural catheter techniques can involve Seldinger technique, needle-introduced guidewire, or introducer sheath with a tract dilator. The surgical tube or catheter is then connected to a drainage system, which may be a three-chamber drain for fluid or air, or a Heimlich (flutter) valve for pneumothorax. Complications may occur in 3–25% of patients, including inappropriate placement or positioning, organ injury, bleeding, infection, nonfunctioning tube, air leak, dislodgement, and re-expansion pulmonary edema. Conclusions: An understanding of surgical tube thoracostomy and pleural catheter placement is essential for emergency clinicians.