A thoracostomy is a small incision of the

chest wall The thoracic wall or chest wall is the boundary of the thoracic cavity. Structure The bony skeletal part of the thoracic wall is the rib cage, and the rest is made up of muscle, skin, and fasciae. The chest wall has 10 layers, namely (from ...

, with maintenance of the opening for

drainage Drainage is the natural or artificial removal of a surface's water and sub-surface water from an area with excess water. The internal drainage of most agricultural soils can prevent severe waterlogging (anaerobic conditions that harm root gro ...

. It is most commonly used for the treatment of a

pneumothorax A pneumothorax is collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and dyspnea, shortness of breath. In a minority of cases, a one-way valve is ...

. This is performed by physicians, paramedics, and nurses usually via needle thoracostomy or an incision into the chest wall with the insertion of a thoracostomy tube (chest tube) or with a hemostat and the provider's finger (finger thoracostomy).

Medical uses

When air, blood, or other fluids accumulate in the

pleural cavity The pleural cavity, or pleural space (or sometimes intrapleural space), is the potential space between the pleurae of the pleural sac that surrounds each lung. A small amount of serous pleural fluid is maintained in the pleural cavity to enabl ...

it may be drained by thoracostomy. Whereas air in this space (

) may be released by needle thoracostomy, other substances require drainage with a thoracostomy tube.

Contra-indications

There are no absolute

contraindications In medicine, a contraindication is a condition (a situation or factor) that serves as a reason not to take a certain medical treatment due to the harm that it would cause the patient. Contraindication is the opposite of indication, which is a rea ...

to thoracostomy. There are relative contraindications (such as coagulopathies); however, in an emergency setting these are outweighed by the necessity to re-inflate a collapsed lung by draining fluid/air from the space around the lung.

Technique

The standard location for thoracostomy is the triangle of safety. This is an anatomical triangle. The borders of which are; the anterior border of the

latissimus dorsi The latissimus dorsi () is a large, flat muscle on the back that stretches to the sides, behind the arm, and is partly covered by the trapezius on the back near the midline. The word latissimus dorsi (plural: ''latissimi dorsi'') comes from L ...

, the lateral border of the pectoralis major muscle, a line superior to the horizontal level of the

nipple The nipple is a raised region of tissue on the surface of the breast from which, in lactating females, breast milk, milk from the mammary gland leaves the body through the lactiferous ducts to Breastfeeding, nurse an infant. The milk can flow th ...

(or 5th intercostal space), with the apex being below, or at, the

axilla The axilla (: axillae or axillas; also known as the armpit, underarm or oxter) is the area on the human body directly under the shoulder joint. It includes the axillary space, an anatomical space within the shoulder girdle between the arm a ...

. A primary skin incision is made superiorly to the rib to avoid the neurovascular supply that runs inferiorly to the rib. This should be around 4–5 cm long. The clinician will tunnel through the subcutaneous tissue and muscle using forceps to reach the pleural. Further blunt dissection is used to carefully penetrate the pleural cavity. A finger is then inserted into this hole, the finger is swept to feel for lung adhesions to the rib cage and to feel for an inflating lung. This cavity is where a hemothorax or pneumothorax would accumulate. A finger thoracostomy as described here can be the first step in inserting an intercostal chest drain. At this point, a chest tube can be inserted and connected to a one way wale to allow continuous drainage. A Roman sandal tie and U-Stitch are done to secure the chest tube and to ensure that removal of the tube will not produce another pneumothorax. Chest x-ray is performed post-procedure to confirm placement and to check for resolution of the pneumothorax/hemothorax.

Risks and complications

Rare complications are mostly due to placement technique, inexperience of the interventionist, and emergent vs. elective circumstances. The most common complications are recurrent pneumothorax (incomplete recovery, but an expected course), infection, and organ injury (due to mechanical damage). Esophageal injury is rare. If saliva and chyme contents drain from the chest tube, that should raise suspicion of esophageal injury. The main treatment of esophageal injury is surgical repair. The stomach is also rarely injured. Proper technique and not using a

trocar A trocar (or trochar) is a medical device, medical or veterinary medicine, veterinary device used in minimally invasive surgery. Trocars are typically made up of an Wiktionary:awl, awl (which may be metal or plastic with a pointed or tapered tip ...

during the procedure decreases the risk of this from occurring.

References

{{Reflist Emergency medical procedures Pulmonology