• 
• 

Three Part Question

In [patients with significant pleural effusions], does a [chest tube incidentally placed in the lung fissure] have any [effect on adequate drainage of the effusion].

Clinical Scenario

A patient is brought to the emergency department following a motor vehicle accident. He is tachycardic, hypotensive, with decreased breath sounds on the left. The airway is patent. You place a chest tube and there is a sudden rush of air. Vital signs improve. CT of thorax revealed tube postioned in the lung fissure and a small hemothorax. The chest tube has drained 300 ml. You wonder if a chest tube placed in the fissure is adequate for drainage of a hemopneumothorax.

Search Strategy

Medline 1950-04/08 using the OVID interface, Cochrane Library (2008), PubMed clinical queries
[(Fissure.mp) AND (exp Drainage and exp thoracostomy and exp chest tubes)]. LIMIT to human AND English

Search Outcome

35 papers found of which only 2 papers were relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Curtin JJ 1994 Dec U.S.A.	66 chest tubes placed in 58 patients presenting to the emergency department with chest trauma.	Prospective observational study.	38 (58%) of chest tubes were incidentally placed in the pulmonary fissure	The position of the tube with the pleural space did not effect the ability of the tube to drain pleural fluid	None
Webb WR 1984 Jan. U.S.A.	12 patients with inadvertently placed chest tube in the major fissure confirmed by lateral x-ray or CT over a two year period.	Prospective observational study	8 of 12 patients had inadequate drainage of pneumothorax or pleural effusion	placement of an additional chest tube improved drainage in 6/8 patients	No control group for comparison. Patients may have been pre-selected based on poor chest tube function.

Comment(s)

The best evidence is Curtin's study of 66 chest tubes placed in 58 patients. Although, Webb's study contradicts Curtin's findings, the patients in Webb's study may have been preselected based on poor chest tube performance. Furthermore, Webb had no comparison group in his study.

Clinical Bottom Line

Intrafissural placement of chest tubes is common and appear to be equally efficacious in draining pleural fluid in patients with acute chest trauma.

References

1. Curtin, J J. Goodman, L R. Quebbeman, E J. Haasler, G B Thoracostomy tubes after acute chest injury: relationship between location in a pleural fissure and function. American Journal of Roentgenology American Journal of Roentgenology. 163(6):1339-42, 1994 Dec.
2. Webb WR Radiographic recognition of chest tube malposition in the major fissure. Chest 85(1):81-3, 1984 Jan.