The British Journal of Radiology, 73 (2000), 786±790 E 2000 The British Institute of Radiology Pictorial review CT diagnosis of malpositioned chest tubes 1 G GAYER, MD, 1 J ROZENMAN, MD, 1 C HOFFMANN, MD, 1 S APTER, MD, 2 D A SIMANSKY, MD, 2 A YELLIN, MD and 1 Y ITZCHAK, MD Departments of 1 Diagnostic Imaging and 2 Thoracic Surgery, The Chaim Sheba Medical Center, Tel Hashomer 52621, Af liated to the Sackler School of Medicine, Tel Aviv University, Israel Abstract. Insertion of a chest tube into the pleural space is standard management for various pleural disorders. Malpositioning of chest tubes in extrathoracic, intraparenchymal and mediastinal locations and in the ssures is common. Malpositioning results not only in inadequate drainage of air and uid but may also result in increased morbidity and mortality. Diagnosis of a malpositioned tube is sometimes dif cult to establish on a chest radiograph. CT, however, has proven to be extremely accurate in evaluating the position of a chest tube and has often provided additional valuable information with signi cant therapeutic impact. Insertion of a chest tube into the pleural space is standard management for various pulmonary and pleural disorders including pneumothorax, penetrating chest injuries, haemothorax, empyema, chylothorax and bronchopleural stula [1]. Optimal tube placement for uid drainage is a dependent location at the posterior base; for air evacuation, a non-dependent position is preferred, apical and anterior [2]. Malpositioning of chest tubes is common, especially in traumatic chest injuries when a tube is often inserted under suboptimal conditions at the site of the accident with a trocar technique. This technique is more often associated with complications than when using blunt dissection for insertion [3]. Malpositioning not only results in inadequate drainage of air and uid but also increased morbidity and mortality [3]. Malpositioned chest tubes therefore usually require immediate repositioning or replacement. Diagnosis of a malpositioned tube is sometimes dif cult to establish because clinical manifestations may be absent [3±5] and a bed-side chest radiograph is usually unreliable in demonstrating the exact location of the tube [2, 5]. CT, however, is extremely accurate in evaluating the position of a chest tube and often provides additional valuable information with signi cant therapeutic impact [3]. The aim of this pictorial review is to provide an overview of malpositioned chest tubes diagnosed on CT. Received 14 October 1999 and accepted 20 December 1999. Recognition of malpositioned chest tubes on CT The superiority of CT over plain radiography in the assessment of malpositioned chest tubes has been reported previously [3, 6]. CT is indicated when a chest tube does not drain adequately and the chest radiograph is non-contributory. The tube can then be visualized over its entire course with accurate location of its tip (Figure 1). Different window settings are necessary, as pulmonary and pleural lesions may conceal the course of the tube on a lung window. A bone window may be of advantage in an extrapleural tube location, where its attenuation may be similar to that of the ribs (Figure 2). In addition, thin sections in a lung window setting may clarify whether a tube is intra ssural or intraparenchymal [3]. Intraparenchymal tube placement An intraparenchymal chest tube position is most likely to occur with pre-existing pulmonary disease or pleural adhesions [1, 4, 7]. On CT, the tube is seen traversing the lung (Figure 1). Sometimes there is increased attenuation around the tube, probably representing a haematoma due to lung laceration (Figure 3) [3]. A parenchymal tract may sometimes remain after removal of a tube that had been located in the lung parenchyma (Figure 1). These tracts may persist for many years [4]. A chronic bronchopleural stula or lung abscess may also result [3, 7]. Intra ssural tube placement A chest tube is considered to be intra ssural when it is outlined by a residual pneumothorax or when it is located in the region of a ssure but 786 The British Journal of Radiology, July 2000
Pictorial review: CT diagnosis of malpositioned chest tubes without areas of an intraparenchymal opacity around it (Figure 4) [3]. The signi cance of chest tubes within a ssure is controversial. Stark et al [6] found that intra ssural tubes correlated with a lengthy and complicated hospital course, including persistent fever and prolonged tube drainage. In contrast, Curtin et al [8] reported that a large percentage of tubes placed for acute chest trauma lie within a pleural ssure and appear to function as effectively as those located elsewhere in the pleural space. They suggest that close clinical and radiographic monitoring of chest tube function could indicate a more individual and effective approach to the management of intra ssural tubes. Mediastinal tube placement A tube that has been introduced too far into the thorax may reach the mediastinum. On CT, the position of the tube can easily be seen abutting the mediastinum (Figure 5). Reported complications include perforation of the heart, the pulmonary artery and the oesophagus [9±12]. Chest wall tube placement When a tube tip is positioned outside the parietal pleura it is considered to be in the chest wall [3]. Contiguous sections have to be thoroughly inspected to ascertain the location of the tip outside the thorax (Figures 2 and 4). Inserting the tube too cranially and too medially may cause bleeding from the pectoralis major muscle (Figure 6), especially in men, and may damage the breast in women [7]. High insertion in the posterior chest wall has resulted in Horner's syndrome [13]. Abdominal placement of a chest tube When the tube is placed too low it may enter the peritoneal cavity and can be seen on CT with the tip below the diaphragm. The spleen (Figure 7) and liver (Figure 8) have been injured most commonly in such cases. Gastric injury from a trocar has also been reported [7]. Figure 1. Malpositioned intraparenchymal tube, inserted to drain a pneumothorax in a 7-year-old girl. Supine chest radiograph. A tube is superimposed on the upper left lung eld. A left pneumothorax is present. CT the same day with the patient prone shows the tube is intraparenchymal and does not reach the loculated anterior pneumothorax. Some loculated pleural effusion is seen posteriorly. CT 6 days later, after removal of the tube, with the patient supine. There is a parenchymal tract in the course of the removed malpositioned tube in the left lung. Another tube, inserted anteriorly, drains the pneumothorax. The British Journal of Radiology, July 2000 787
G Gayer, J Rozenman, C Hoffmann et al Figure 2. A 65-year-old woman after a motor vehicle accident had a tube inserted for a left pneumothorax. CT shows extensive left subcutaneous emphysema and bilateral pulmonary consolidation. The chest tube lies within the soft tissues of the posterior left chest wall, its tip abutting the spinous process of a thoracic vertebra (arrow). The dense tube within the left hemithorax (arrowhead) was inserted during surgery. Figure 3. A 37-year-old man after a road accident. CT (mediastinal window) demonstrates a tube entering through the left anterior chest wall, coursing posteriorly in the apex of the left lung. Lung window: increased attenuation of the lung parenchyma surrounding the tube is probably haematoma. Figure 4. A 57-year-old woman with sclerosing cholangitis who developed sepsis, multi-organ failure and anasarca. Chest CT (mediastinal window), contiguous sections at the lung base show the right tube within the oblique ssure, crossing the hemithorax, with its tip very close to the dilated contrast- lled oesophagus. The tip of a left chest tube lies in the left lateral chest wall (arrow in ). 788 The British Journal of Radiology, July 2000
Pictorial review: CT diagnosis of malpositioned chest tubes Figure 5. A 3.5-year-old girl with a right pleural effusion and a lung in ltrate. A tube was inserted into the right hemithorax. Chest CT (lung window): a right hydropneumothorax is present. Part of the tube is seen anteriorly; its tip cannot be accurately de ned. Chest CT (mediastinal window, same level as ): again the tip of the tube is not well visualized owing to artefacts from a metallic device on the left chest wall, but it probably abuts the superior vena cava and the ascending aorta. Figure 6. A gunshot wound at the level of D3 in a 29-year-old man. CT demonstrates bilateral pneumothoraces. A tube has been inserted anteriorly to drain the left pneumothorax, causing a haematoma in the pectoralis major muscle (asterisk). Figure 7. A 56-year-old woman with a gun shot wound to the chest. On a chest radiograph in deep inspiration, a tube is seen traversing the left costophrenic angle (arrow). A repeat chest radiograph in expiration 12 h later. The course of the tube now seems to be subdiaphragmatic (arrow). A second tube has been inserted more cranially. On CT, the lower tube is seen entering the lateral aspect of the spleen (arrow). The British Journal of Radiology, July 2000 789
G Gayer, J Rozenman, C Hoffmann et al Figure 8. A 36-year-old woman with bilateral pleural effusions and pneumonia. Failed attempt to insert a right thoracostomy tube in the 5th intercostal space. CT was performed because of a drastic drop of haemoglobin. Chest CT (mediastinal window) at level of diaphragm shows a right pleural effusion posterior to an atelectatic segment of the right lower lobe. The lateral aspect of the liver is surrounded by uid of high density. Air bubbles within the peritoneal uid indicate an intraabdominal placement of the tube. A left tube had been inserted earlier to drain the left pleural effusion. An upper abdominal section shows the large amount of uid surrounding the right lobe of the liver and the spleen. The inhomogeneous uid is of high density (64 HU), corresponding to fresh blood, probably owing to damage to the liver. References 1. Miller KS, Sahn SA. Chest tubes: indications, technique, management and complications. Chest 1987;91:258±64. 2. Maurer JR, Friedman PJ, Wing VW. Thoracostomy tube in an interlobar ssure: radiologic recognition of a potential problem. AJR 1982;139:1155±61. 3. Baldt MM, Bankier AA, Germann PS, Poschl GP, Skrbensky GT, Herold CJ. Complications after emergency tube thoracostomy: assessment with CT. Radiology 1995;195:539±43. 4. Fraser RS. Lung perforation complicating tube thoracostomy: pathologic description of three cases. Hum Pathol 1988;19:518±23. 5. Gerard PS, Kaldawi E, Litani V, Lenora RA, Tessler S. Right-sided pneumothorax as a result of a left-sided chest tube. Chest 1993;103:1602±3. 6. Stark DD, Federle MP, Goodman PC. CT and radiographic assessment of tube thoracostomy. AJR 1983;141:253±8. 7. Millikan JS, Moore EE, Steiner E, Aragon GE, Van Way CW. Complications of tube thoracostomy for acute trauma. Am J Surg 1980;140:738±41. 8. Curtin JJ, Goodman LR, Quebbeman EJ, Haasler GB. Thoracostomy tubes after acute chest injury: relationship between location in a pleural ssure and function. AJR 1994;163:1339±42. 9. Meisel S, Ram Z, Priel I, Nass D, Lieberman P. Another complication of thoracostomyðperforation of the right atrium. Chest 1990;98:772±3. 10. Johnson JF, Wright DR. Chest tube perforation of esophagus following repair of esophageal atresia. J Pediatr Surg 1990;25:1227±30. 11. Shapira OM, Aldea GS, Kupferschmid J, Shemin RJ. Delayed perforation of the esophagus by a closed tube thoracostomy. Chest 1993;104:1897±8. 12. Van Kralingen KW, Stam J, Rauwerda J. Complications of thoracostomyðletter to the editor. Chest 1991;100:886. 13. Bertino RE, Wesbey GE, Johnson RJ. Horner syndrome occurring as a complication of chest tube placement. Radiology 1987;164:745. 790 The British Journal of Radiology, July 2000