Steering the wheel towards the standard of care: Proposal of a step-by-step ultrasound-guided emergency chest tube drainage and literature review

Abstract

Background: Chest tube drainage is a common procedure performed by physicians in the emergency setting. Complications may arise in up to 25% of the cases. These vary from drain misplacement to lethal iatrogenic injuries. Ultrasound provides adequate visualization and correct identification of the insertion site, allows the exclusion of a vulnerable intercostal artery, and enables timely diagnosis of drain malpositioning. Although feasible, ultrasound-guided techniques are underused and seldom applied during chest drainage. One reason for that is the lack of a comprehensive step-by-step description incorporating these techniques. This article aims to describe a standardized ultrasound-guided chest tube drainage technique, and also review the evidence supporting its potential benefits. Materials and methods: we conducted a thorough literature search on ultrasound techniques regarding the identification of the diaphragm, the neurovascular intercostal bundle, and the position of the chest drain. Also, we analyzed published articles about complications of chest drainage. Results: we propose a feasible step-by-step ultrasound-guided technique of chest drainage and discuss why this technique should be incorporated in the routine practice. Conclusion: ultrasound guidance should be incorporated in chest drainage in a stepwise fashion. Although intuitively safer, future randomized studies are warranted to support this technique.