Chest drain insertion is not a harmless procedure--are we doing it safely?

Assessing Chest Tube Insertion Skills Using a Porcine Rib Model-A Validity Study

INTRODUCTION

Assessments require sufficient validity evidence before their use. The Assessment for Competence in Chest Tube Insertion (ACTION) tool evaluates proficiency in chest tube insertion (CTI), combining a rating scale and an error checklist. The aim of this study was to collect validity evidence for the ACTION tool on a porcine rib model according to the Messick framework.

METHODS

A rib model, consisting of a porcine hemithorax that was placed in a wooden frame, was used as simulator. Participants were recruited from the departments of surgery, pulmonology, and emergency medicine. After familiarization with the rib model and the equipment, standardized instructions and clinical context were provided. They performed 2 CTIs while being scored with the ACTION tool. All performances were assessed live by 1 rater and by 3 blinded raters using video recordings. Generalizability-analysis was performed and mean scores and errors of both groups on the first performance were compared. A pass/fail score was established using the contrasting groups' method.

RESULTS

Nine novice and 8 experienced participants completed the study. Generalizability coefficients where high for the rating scale (0.92) and the error checklist (0.87). In the first CTI, novices scored lower than the experienced group (38.1/68 vs. 47.1/68, P = 0.042), but no difference was observed on the error checklist. A pass/fail score of 44/68 was established.

CONCLUSION

A solid validity argument for the ACTION tool's rating scale on a porcine rib model is presented, allowing formative and summative assessment of procedural skills during training before patient contact.

Critical tasks and errors associated with intercostal chest drain insertion

INTRODUCTION

To describe critical tasks and errors associated with intercostal chest drain insertion, in order to develop enhanced procedural guidelines for task performance and training.

METHODS

Expert emergency medicine physicians participated in a three-phased study. First, hierarchical task analyses was used to identify tasks, sub-tasks, and the sequence of tasks. Second, systematic human error reduction and prediction approach was used to identify and classify the errors associated with each sub-task culminating in a probability, criticality, and detectability rating for each error. Third, failure modes, effects and criticality analysis technique was used to convert probability and criticality estimates to occurrence and severity scores. Criticality index score, a measure of the propensity for the error to cause harm or procedural failure for each error, was calculated and the top 20 errors most likely to cause harm were ranked.

RESULTS

Thirteen tasks and 61 sub-tasks were identified and yielded 86 potential errors. Error classification included errors of action, checking, and selection. The error with the highest criticality score was 'identifying a point of entry lower than the fifth intercostal space'. The top four ranked errors all relate to the identification and correct marking of the location site for the intercostal drain within the safe triangle.

CONCLUSIONS

Tasks and sub-tasks associated with intercostal chest drain insertion was described and evaluated for criticality. The most critical task was the correct identification of a safe insertion point. Applications include development of procedural guidelines with tasks vulnerable to error highlighted and training interventions that promotes safe task performance.

Radiologic assessment of the optimal point for tube thoracostomy using the sternum as a landmark: a computed tomography-based analysis

Purpose

This study aimed at developing a novel tube thoracostomy technique using the sternum, a fixed anatomical structure, as an indicator to reduce the possibility of incorrect chest tube positioning and complications in patients with chest trauma.

Methods

This retrospective study analyzed the data of 184 patients with chest trauma who were aged ≥18 years, visited a single regional trauma center in Korea between April and June 2022, and underwent chest computed tomography (CT) with their arms down. The conventional gold standard, 5th intercostal space (ICS) method, was compared to the lower 1/2, 1/3, and 1/4 of the sternum method by analyzing CT images.

Results

When virtual tube thoracostomy routes were drawn at the mid-axillary line at the 5th ICS level, 150 patients (81.5%) on the right side and 179 patients (97.3%) on the left did not pass the diaphragm. However, at the lower 1/2 of the sternum level, 171 patients (92.9%, P<0.001) on the right and 182 patients (98.9%, P= 0.250) on the left did not pass the diaphragm. At the 5th ICS level, 129 patients (70.1%) on the right and 156 patients (84.8%) on the left were located in the safety zone and did not pass the diaphragm. Alternatively, at the lower 1/2, 1/3, and 1/4 of the sternum level, 139 (75.5%, P=0.185), 49 (26.6%, P<0.001), and 10 (5.4%, P<0.001), respectively, on the right, and 146 (79.3%, P=0.041), 69 (37.5%, P<0.001), and 16 (8.7%, P<0.001) on the left were located in the safety zone and did not pass the diaphragm. Compared to the conventional 5th ICS method, the sternum 1/2 method had a safety zone prediction sensitivity of 90.0% to 90.7%, and 97.3% to 100% sensitivity for not passing the diaphragm.

Conclusions

Using the sternum length as a tube thoracostomy indicator might be feasible.

A Novel Device With Improved Outcomes for Tube Thoracostomy

INTRODUCTION

Tube thoracostomy is a common procedure for which competency is expected of all trauma providers, both surgical and nonsurgical. Although surgery residents have fewer complications than other resident specialties, complications relating to position and insertion are reported. We hypothesized the use of our novel chest tube placement device will improve chest tube placement efficiency while maintaining accuracy compared to the open Kelly clamp technique across multiple specialties.

METHODS

A swine lab was conducted through an approved Institutional Animal Care and Use Committee device testing protocol. After a preprocedure, tutorial participants placed chest tubes with the device and Kelly clamps through predetermined incision sites. Placement positioning was determined by a postplacement chest X-ray. One way analysis of variance was used for intratechnique comparisons. Time to placement was compared using paired t-test; P- values of <0.05 were considered significant.

RESULTS

Intrathoracic device placement occurred with 94.4% (N = 68) of placements compared to 93.1% (N = 67) of Kelly clamp placements (P = 0.73). The device-placed chest tubes were apically positioned 94.4% (N = 68) compared to 66.7% (N = 48) (P < 0.01) of Kelly clamp-placed chest tubes. Novel device use chest tube placement was significantly faster with a mean time of 39.3 (±27.7) s compared to 61.5 (±38.6) s for the Kelly clamp (P < 0.01).

CONCLUSIONS

In this proof of concept study, our chest tube placement device improved efficiency and accuracy in chest tube placement when compared to the open Kelly clamp technique. This finding was consistent across thoracic trauma providers, including general surgery residents.

Interpleural location of chest drain on ultrasound excludes pneumothorax and associates with a low degree of chest drain foreshortening on the antero-posterior chest X-ray

Background

The role of chest drain (CD) location by bedside imaging methods in the diagnosis of pneumothorax has not been explored in a prospective study yet.

Methods

Covid-19 ARDS patients with pneumothorax were prospectively monitored with chest ultrasound (CUS) and antero-posterior X-ray (CR) performed after drainage in the safe triangle. CD foreshortening was estimated as a decrease of chest drain index (CDI = length of CD in chest taken from CR/depth of insertion on CD scale + 5 cm). The angle of inclination of the CD was measured between the horizontal line and the CD at the point where it enters pleural space on CR.

Results

Of the total 106 pneumothorax cases 80 patients had full lung expansion on CUS, the CD was located by CUS in 69 (86%), the CDI was 0.99 (0.88–1.06). 26 cases had a residual pneumothorax after drainage (24.5%), the CD was located by CUS in 31%, the CDI was 0.76 (0.6–0.93),p < 0.01. The risk ratio for a pneumothorax in a patient with not visible CD between the pleural layers on CUS and an associated low CDI on CR was 5.97, p˂0.0001. For the patients with a steep angle of inclination (> 50°) of the CD, the risk ratio for pneumothorax was not significant (p < 0.17). A continued air leak from the CD after drainage is related to the risk for a residual pneumothorax (RR 2.27, p = 0.003).

Conclusion

Absence of a CD on CUS post drainage, low CDI on CR and continuous air leak significantly associate with residual occult pneumothorax which may evade diagnosis on an antero-posterior CR.

Point-of-care ultrasound thoracic “Quick Look” identifies potentially dangerous chest tube insertion sites

PURPOSE

Emergency and trauma physicians typically rely on anatomic landmarks to determine the proper intercostal space for emergent tube thoracostomy. However, physicians using this technique select a potentially dangerous insertion site too inferior in nearly one-third of cases, which have the potential to result in subdiaphragmatic puncture. We investigated a point-of-care ultrasound (POCUS) thoracic "Quick Look" procedure as a technique to allow visualization of underlying structures to avoid tube misplacement.

METHODS

We performed an observational study of adult emergency department patients and their treating physicians. The patient's emergency physician was asked to rapidly identify and mark a hypothetical tube thoracostomy insertion site on the patient's chest wall. An ultrasound fellow then performed a POCUS thoracic "Quick Look" exam with a phased-array probe placed directly over the marked site. Over one regular respiratory cycle, the identification of standard lung pattern was considered a negative scan whereas visualization of the diaphragm with underlying liver or spleen was considered a positive scan. Time for completion of the "Quick Look" scan was measured and inter-rater reliability was determined through image review by a single, blinded ultrasound director.

RESULTS

Seventy-six thoracic "Quick Look" scans were performed on patient subjects, of which 17% (13/76, 95%CI 8-26%) were positive. The average time for performing the "Quick Look" exam was 43 s (95%CI 30-57). Inter-rater reliability of the thoracic "Quick Look" was excellent (κ = 0.95).

CONCLUSION

Thoracic "Quick Look" exams performed at mock chest tube insertion sites demonstrated potentially dangerous insertions in 17% of the cases. POCUS thoracic "Quick Look" may be a rapid and reliable technique that improves safety when placing an emergent chest tube.

Which Model Is Better to Teach How to Perform Tube Thoracostomy: Synthetic, Cadaver, or Animal?

INTRODUCTION

The lack of standardized skill training reported by medical students in performing tube thoracostomies may be associated with higher complications. The ideal training model is yet to be determined. This study sought to evaluate three different models.

METHODS

Between 2015 and 2017, 204 last-year medical students of Universidade de São Paulo with no prior training in tube thoracostomy were randomized into three groups: cadaver, pig, and synthetic models. All groups performed 1-d tube thoracostomy hands-on training and a 40-min theoretical class. The knowledge acquisition was measured by a comparison between a theoretical test before and 3 wk after the class, and the skills improvement was evaluated by a comparison between the skills test on the same day of the hands-on training and another after 24 wk (the retention skill test). A questionnaire was submitted to evaluate their satisfaction rate and self-reported confidence, as per a Likert scale.

RESULTS

The theoretical post-test score was higher compared to the pretest score in all groups (P < 0.001). The retention skills test in the cadaver and synthetic groups decreased compared to the skills test (P = 0.01 and P = 0.007, respectively). There was no difference between the groups either in the theoretical test or in the skills test. Student satisfaction was higher in the cadaver and pig groups. The confidence perception increased in all groups after the training.

CONCLUSIONS

The models used for tube thoracostomy training appear to have a similar impact on skills retention, knowledge acquisition, and confidence. Although the satisfaction rate is lower for the synthetic model, it has no biological risk or ethical issues and is more feasible.

Development and validation of the first performance assessment scale for interdisciplinary chest tube insertion: a prospective multicenter study

PURPOSE

Chest tube insertion requires interdisciplinary teamwork including an emergency surgeon or physician in conjunction with a nurse. The purpose of the study was to validate an interdisciplinary performance assessment scale for chest tube insertion developed from literature analysis.

METHODS

This prospective study took place in the simulation center of the University of Paris. The participants included untrained emergency/intensivist residents and trained novice emergency/intensivist physicians with less than 2 years of clinical experience and 6 months following training in thoracostomy, and nursing students. Each interdisciplinary pair participated in a high-fidelity simulation session. Two independent observers (O1 and O2) evaluated 61 items. Internal coherence using the Cronbach's α coefficient, intraclass correlation coefficient (ICC), and correlation of scores by regression analysis (R2) were analyzed. Comparison between O1 and O2 mean scores used a t test and F test for SDs. p Value < 0.05 was significant.

RESULTS

From an initial selection of 11,277 articles, 19 were selected to create the initial scale. The final scale comprises 61 items scored out of 80, including 24 items for nursing items, 24 items for medical competence, and 13 mixed items for the competence of both. 40 simulations including 80 participants were evaluated. Cronbach's α = 0.76, ICC = 0.92, R2 = 0.88. There was no difference between the observers' assessments of means (p = 0.82) and SDs (p = 0.92). Score was 51.6 ± 5.9 in the group of untrained residents and nursing student, and 57.2 ± 2.8 in the trained group of novice physicians and nursing students (p = 0.0003).

CONCLUSIONS

This first performance assessment scale for interdisciplinary chest tube insertion is valid and reliable.

Using an application to measure trainees' procedural knowledge before chest tube insertion

PURPOSE OF THE STUDY

To collect validity evidence for the chest tube insertion (CTI) test mode on the medical simulation application Touch Surgery. This was done by using Messick's contemporary framework.

METHODS

Novice, intermediate and experienced participants provided informed consent and demographic information. After familiarisation with the application, they completed the CTI test mode. Validity evidence was collected from four sources: content, response process, relation to other variables and consequences. A post-study questionnaire with 5-point Likert scales assessed the perceived realism, relevance and utility of the assessment. Mean scores of the three groups were compared.

RESULTS

A total of 25 novices, 11 intermediates and 19 experienced participants were recruited. Content evidence was collected by an expert in CTI and was based on published literature and guidelines. All users were familiarised with the application, and received standardised instructions throughout the test. Most users rated the simulation as realistic and suitable to assess cognitive skills. Novices received significantly lower (55.9±7.5) test mode scores than intermediates (80.6±4.4) (p<0.001) and experienced participants (82.3±5.3) (p<0.001). There was no significant difference in score between intermediate and experienced participants (p=0.75). Consequences evidence was provided by establishing a pass/fail score of 71% using the contrasting groups method, which resulted in one observed false positive and no false negatives.

CONCLUSION

A robust validity argument was constructed for the CTI test mode, which can be implemented in surgical curricula to assess learners' cognitive skills prior to hands-on simulation practice.

Novel Approach to Ultrasound-Guided Thoracostomy

OBJECTIVES

Thoracostomy is often a required treatment in patients with thoracic trauma; however, performing a thoracostomy using traditional techniques can have complications. Ultrasound can be a beneficial tool for identifying the correct thoracostomy insertion site. We designed a randomized prospective study to assess if ultrasound guidance can improve thoracostomy site identification over traditional techniques.

METHODS

Emergency medicine residents were randomly assigned to use palpation or ultrasound to identify a safe insertion site for thoracostomy placement. The target population comprised of hemodynamically stable trauma patients who received an extended focused assessment with sonography for trauma (EFAST) and a chest computed tomography (CT) exam. The resident placed a radiopaque marker on the skin of the patient where a safe intercostal space was believed to be located, either by palpation or ultrasound. Clinical ultrasound faculty reviewed the CT to confirm marker placement relative to the diaphragm. A Fischer's exact test was used to analyze the groups.

RESULTS

One hundred and forty-seven patients were enrolled in the study, 75 in the ultrasound group and 72 in the landmark group. This resulted in the placement of 271 total thoracostomy site markers, 142 by ultrasound and 129 by palpation and landmarks. The ultrasound group correctly identified thoracostomy insertion sites above the diaphragm in 97.2% (138/142) of patients, while the palpation group identified a safe insertion site in 88.4% (114/129) of patients (P = .0073).

CONCLUSION

This study found that emergency medicine residents are more likely to identify a safe tube thoracostomy insertion site in trauma patients by using ultrasound, as compared to using landmarks and palpation.

Ultrasound-Guided Pleural Investigations: Fluid, Air, and Biopsy

Pleural diseases are frequently encountered across multiple inpatient and outpatient settings, making pleural drainage and sampling one of the most common medical procedures. With the widespread adoption of bedside ultrasound examination, ultrasound machines are now readily available in many clinical settings, providing both diagnostic and procedural guidance. The modern management of pleural disease is dominated by ultrasound assessment with strong evidence supporting its use to guide pleural interventions. Here, we review the current landscape of ultrasound use to guide pleural drainage, pneumothorax management, and pleural biopsy.

Patient Safety During Chest Drain Insertion-A Survey of Current Practice

OBJECTIVES

The aim of this study was to identify the degree of awareness of the current guidelines and common practices for pleural drain insertion.

METHODS

A 10-item questionnaire was sent electronically to junior physicians from 4 different hospitals in the South Eastern Sydney and Illawarra Shoalhaven Local Health District. Participants were asked to give their level of experience and management practices for chest drain insertion.

RESULTS

A total of 94 junior medical officers from 4 hospitals in the district completed the survey. More than 20% had never inserted a chest drain at the time; 72% had primarily learned from bedside teaching and peer learning, but 11% had no training at all. More than 50% of physicians felt that the biggest threat to the procedure was their own lack of confidence for drain insertion. Despite current guidelines, 25% insert chest drains routinely without the aid of ultrasound. A third of interviewees were aware of local guidelines but had not read them. Most physicians (86%) believe that formal standardized training should be available for junior physicians.

CONCLUSIONS

Our findings demonstrate the ongoing need for improved procedural training in chest drain insertion, with emphasis on mandatory thoracic ultrasound. We consider it important to continue to raise concern and awareness that chest drain insertion is not a harmless procedure, and further physician procedural competence is required.

Management of Pleural Effusions in the Emergency Department

BACKGROUND

In symptomatic patients, admitted in emergency department for acute chest pain and dyspnea, who require an urgent treatment, a rapid diagnosis and prompt management of massive pleural effusion or hemothorax can be lifesaving.

AIM

The aim of this review was to summarize the current diagnostic and therapeutic approaches for the management of the main types of pleural effusions that physicians can have in an emergency department setting.

METHODS

Current literature about the topic was reviewed and critically reported, adding the experience of the authors in the management of pleural effusions in emergency settings.

RESULTS

The paper analyzed the main types of pleural effusions that physicians can have to treat. It illustrated the diagnostic steps by the principal radiological instruments, with a particular emphasis to the role of ultrasonography, in facilitating diagnosis and guiding invasive procedures. Then, the principal procedures, like thoracentesis and insertion of small and large bore chest drains, are indicated and illustrated according to the characteristics and the amount of the effusion and patient clinical conditions.

CONCLUSION

The emergency physician must have a systematic approach that allows rapid recognition, clinical cause identification and definitive management of potential urgent pleural effusions.

Complications in tube thoracostomy: Systematic review and meta-analysis

BACKGROUND

Tube thoracostomy (TT) complications and their reported rates are highly variable (1-40%) and inconsistently classified. Consistent TT complication classification must be applied to compare reported literature to standardize TT placement. We aim to determine the overall TT-related complication rates in patients receiving TT for traumatic indications using uniform definitions.

METHODS

Systematic review and meta-analysis was performed assessing TT-related complications. Comprehensive search of several databases (1975-2015) was conducted. We included studies that reported on bedside TT insertion (≥22 Fr) in trauma patients. Data were abstracted from eligible articles by independent reviewers with discrepancies reconciled by a third. Analyses were based on complication category subtypes: insertional, positional, removal, infection/immunologic/education, and malfunction.

RESULTS

Database search resulted in 478 studies; after applying criteria 29 studies were analyzed representing 4,981 TTs. Injury mechanisms included blunt 60% (49-71), stab 27% (17-34), and gunshot 13% (7.8-10). Overall, median complication rate was 19% (95% confidence interval, 14-24.3). Complication subtypes included insertional (15.3%), positional (53.1%), removal (16.2%), infection/immunologic (14.8%), and malfunction (0.6%). Complication rates did not change significantly over time for insertional, immunologic, or removal p = 0.8. Over time, there was a decrease in infectious TT-related complications as well as an increase in positional TT complications.

CONCLUSION

Generation of evidence-based approaches to improve TT insertion outcomes is difficult because a variety of complication classifications has been used. This meta-analysis of complications after TT insertion in trauma patients suggests that complications have not changed over time remaining stable at 19% over the past three decades.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, level III.

Ensuring basic competency in chest tube insertion using a simulated scenario: an international validation study

Introduction

Chest tube insertion can be associated with serious complications. A structured training programme is needed to minimise complications and enhance patient safety. Novices should pass a reliable test with solid evidence of validity before performing the procedure supervised on patients. The aim of this study was to establish a credible pass/fail standard.

Methods

We used an established assessment tool the Chest Tube Insertion Competency Test (TUBE-iCOMPT). Validity evidence was explored according to Messick’s five sources of validity. Two methods were used to establish a credible pass/fail standard. Contrasting groups’ method: 34 doctors (23 novices and 11 experienced surgeons) performed the procedure twice and all procedures were video recorded, edited, blinded and rated by two independent, international raters. Modified Angoff method: seven thoracic surgeons individually determined the scores that defined the pass/fail criteria. The data was gathered in Copenhagen, Denmark and Riyadh, Saudi Arabia.

Results

Internal consistency reliability was calculated as Cronbach’s alpha to 0.94. The generalisability coefficient with two raters and two procedures was 0.91. Mean scores were 50.7 (SD±13.2) and 74.7 (SD±4.8) for novices and experienced surgeons, respectively (p<0.001). The pass/fail score of 62 points resulted in zero false negatives and only three false positives.

Discussion

We have gathered valuable additional validity evidence for the assessment tool TUBE-iCOMPT including establishment of a credible pass/fail score. The TUBE-iCOMPT can now be integrated in mastery learning programmes to ensure competency before independent practice.

Ensuring Basic Competence in Thoracentesis

BACKGROUND

Trocar pigtail catheter thoracentesis (TPCT) is a common procedure often performed by junior physicians. Simulation-based training may effectively train physicians in the procedure prior to performing it on patients. An assessment tool with solid validity evidence is necessary to ensure sufficient procedural competence.

OBJECTIVES

Our study objectives were (1) to collect evidence of validity for a newly developed pigtail catheter assessment tool (Thoracentesis Assessment Tool [ThorAT]) developed for the evaluation of TPCT performance and (2) to establish a pass/fail score for summative assessment.

METHODS

We assessed the validity evidence for the ThorAT using the recommended framework for validity by Messick. Thirty-four participants completed two consecutive procedures and their performance was assessed by two blinded, independent raters using the ThorAT. We compared performance scores to test whether the assessment tool was able to discern between the two groups, and a pass/fail score was established.

RESULTS

The assessment tool was able to discriminate between the two groups in terms of competence level. Experienced physicians received significantly higher test scores than novices in both the first and second procedure. A pass/fail score of 25.2 points was established, resulting in 4 (17%) passing novices and 1 (9%) failing experienced participant in the first procedure. In the second procedure 9 (39%) novices passed and 2 (18%) experienced participants failed.

CONCLUSIONS

This study provides a tool for summative assessment of competence in TPCT. Strong validity evidence was gathered from five sources of evidence. A simulation-based training program using the ThorAT could ensure competence before performing thoracentesis on patients.

Ultrasound-guided thoracostomy site identification in healthy volunteers

BACKGROUND

Traditional landmark thoracostomy technique has a known complication rate up to 30%. The goal of this study is to determine whether novice providers could more accurately identify the appropriate intercostal site for thoracostomy by ultrasound guidance.

METHODS

33 emergency medicine residents and medical students volunteered to participate in this study during routine thoracostomy tube education. A healthy volunteer was used as the standardized patient for this study. An experienced physician sonographer used ultrasound to locate a site at mid-axillary line between ribs 4 and 5 and marked the site with invisible ink that can only be revealed with a commercially available UV LED light. Participants were asked to identify the thoracostomy site by placing an opaque marker where they would make their incision. The distance from the correct insertion site was measured in rib spaces. The participants were then given a brief hands-on training session using ultrasound to identify the diaphragm and count rib spaces. The participants were then asked to use ultrasound to identify the proper thoracostomy site and mark it with an opaque marker. The distance from the proper insertion site was measured and recorded in rib spaces.

RESULTS

The participants correctly identified the pre-determined intercostal space using palpation 48% (16/33) of the time, versus the ultrasound group who identified the proper intercostal space 91% (30/33) of the time. On average, the traditional technique was placed 0.88 rib spaces away (95 CI 0.43-1.03), while the ultrasound-guided technique was placed 0.09 rib spaces away (95 CI 0.0-0.19) [P = 0.003].

CONCLUSIONS

The ability to accurately locate the correct intercostal space for thoracostomy incision was improved under ultrasound guidance. Further studies are warranted to determine if this ultrasound-guided technique will decrease complications with chest tube insertion and improve patient outcomes.

X-ray indices of chest drain malposition after insertion for drainage of pneumothorax in mechanically ventilated critically ill patients

BACKGROUND

Chest drain (CD) migration in the pleural cavity may result in inadequate drainage of pneumothorax. The aim of this study was to assess several parameters that might help in diagnosing CD migration on chest X-ray (CXR).

METHODS

Patients with a CD inserted from the safe triangle with a subsequent supine CXR and CT scan performed less than 24 hours apart were assessed for CD foreshortening, angle of inclination of the CD, and CD tortuosity. CD foreshortening was expressed as a ratio between CD length measured in coronal plane only and CD length inside the pleural cavity measured on CT. The angle of inclination of the CD was measured as the angle between the horizontal line and CD at the pleural space entry on CXR. CD tortuosity was calculated as a ratio between the distance from CD pleural space entry to the tip of the CD and the length of CD from the pleural space entry to its tip on CXR.

RESULTS

Altogether 28 patients were included in the study. The median time between the CXR and CT examinations was 5.4 hours (IQR, 3.8-6.9 hours). CD foreshortening was the best clue of a misplaced CD with AUC of 0.93, 100% sensitivity and 88% specificity for a cut-off value of 82%. The angle of CD inclination was greater in patients with misplaced CD with AUC of 0.83, 75% sensitivity and 92% specificity for a cut-off of 50 degrees. The performance of CD tortuosity was poor.

CONCLUSIONS

Greater foreshortening of the CD and a steep angle of inclination of the CD above the horizontal at chest entry should raise suspicion of CD migration and mandate further investigation by chest ultrasound to rule out residual pneumothorax occult on CXR.

Tube Thoracostomy Complications Increase Cost

BACKGROUND

Tube thoracostomy (TT) can be an effective therapy for thoracic pathologies. Ineffective placement of TT is common and associated with significant complications. Complications require additional interventions to repair damaged tissues or replace dysfunctional TT. We hypothesize that complicated TT insertion increases cost to the hospital system.

METHODS

Adult trauma patients requiring TT at a level 1 trauma center (2012-2013) were reviewed. Intraoperative or image-guided TT placements were excluded. Baseline demographics and TT insertion cost (normalized and assigned by hospital billing records) were recorded. Costs included initial TT equipment, radiographs, and subsequent operative or radiologic intervention to correct TT complications. Complications were categorized using previously validated method. Secondary outcomes included: number of TT inserted, number of chest radiographs performed, and TT dwell time utilizing a standardized TT discontinuation protocol.

RESULTS

A total of 154 patients with 246 TT were included. Ninety TT (37%) had complication. Complication categories are postremoval (n = 15, 16.7%), insertional (n = 13, 14.4%), positional (n = 62, 68.9%). Overall median complicated TT cost was 9 times greater than uncomplicated TT insertion, p = 0.001. Insertional complications median cost 21 times greater than an uncomplicated, due to operative and radiologic interventions (p = 0.0001). Positional and postremoval complication rates increased median cost by 3 times compared to uncomplicated TT (p = 0.03). Operative or radiologic interventions (n = 10) were performed for organ injury or uncontrolled hemo-/pneumothorax. Increased dwell time median [IQR] was associated with complicated TT compared to uncomplicated 3 [1-5] versus 2 [1-3], p = 0.01.

CONCLUSION

TT is a common procedure. TT complications are often considered benign. However, patients with a complicated TT insertion, especially related to insertional subtypes, have markedly increased hospitalization costs due to need for operative or radiologic repair.

LEVEL OF EVIDENCE

Level V-retrospective study.

STUDY TYPE

This is a retrospective single-institution study.

Identifying a safe site for intercostal catheter insertion using the mid-arm point (MAP)

Background: Over 85% of chest injuries requiring surgical intervention can be managed with tube thoracostomy/intercostal catheter (ICC) insertion alone. However, complication rates of ICC insertion have been reported in the literature to be as high as 37%. Insertional complications, including the incorrect identification of the safe zone chest wall location for ICC placement, are common issues, with up to 41% of insertions occurring outside of this safe area. A new biometric approach using the patient's proportional skeletal upper limb anatomy to allow correct identification of the chest wall skin site for ICC insertion may reduce complications. Aim: The aim of this study was to examine the performance of the mid-arm point (MAP) method in identifying the safe zone for ICC insertion. Methods: Thirty healthy volunteers were recruited from The Alfred Hospital, a Level I Adult Trauma Centre in Melbourne, Australia. Blinded investigators used the MAP to measure the mid-point of the adducted arm of each volunteer bilaterally. A skin marking was placed on the anterior axillary line of the adjacent chest wall, and with the arm then abducted to 90 degrees, the underlying intercostal space was identified. Results: Using the MAP method, all of the 120 measurements fell within the ‘safe zone’ of the fourth to sixth intercostal spaces bilaterally. The median intercostal space identified was the fifth space, with investigators finding this in 86% of measurements independent of age, sex, height, weight or side. Conclusion: A simple technique using the MAP is a reliable marker for the identification of the safe zone for ICC insertion in healthy volunteers. The clinical utility for patients undergoing pleural decompression and drainage needs prospective evaluation.

Visually guided tube thoracostomy insertion comparison to standard of care in a large animal model

INTRODUCTION

Tube thoracostomy (TT) is a lifesaving procedure for a variety of thoracic pathologies. The most commonly utilized method for placement involves open dissection and blind insertion. Image guided placement is commonly utilized but is limited by an inability to see distal placement location. Unfortunately, TT is not without complications. We aim to demonstrate the feasibility of a disposable device to allow for visually directed TT placement compared to the standard of care in a large animal model.

METHODS

Three swine were sequentially orotracheally intubated and anesthetized. TT was conducted utilizing a novel visualization device, tube thoracostomy visual trocar (TTVT) and standard of care (open technique). Position of the TT in the chest cavity were recorded using direct thoracoscopic inspection and radiographic imaging with the operator blinded to results. Complications were evaluated using a validated complication grading system. Standard descriptive statistical analyses were performed.

RESULTS

Thirty TT were placed, 15 using TTVT technique, 15 using standard of care open technique. All of the TT placed using TTVT were without complication and in optimal position. Conversely, 27% of TT placed using standard of care open technique resulted in complications. Necropsy revealed no injury to intrathoracic organs.

CONCLUSION

Visual directed TT placement using TTVT is feasible and non-inferior to the standard of care in a large animal model. This improvement in instrumentation has the potential to greatly improve the safety of TT. Further study in humans is required.

LEVEL OF EVIDENCE

Therapeutic Level II.

Intercostal drainage tube or intracardiac drainage tube?

Although insertion of chest drain tubes is a common medical practice, there are risks associated with this procedure, especially when inexperienced physicians perform it. Wrong insertion of the tube has been known to cause morbidity and occasional mortality. We report a case where the left ventricle was accidentally punctured leading to near-exsanguination. This report is to highlight the need for experienced physicians to supervise the procedure and train the younger physician in the safe performance of the procedure.

[Chest decompression in emergency medicine and intensive care]

Decompression of the chest is a life-saving invasive procedure for tension pneumothorax, trauma-associated cardiopulmonary resuscitation or massive haematopneumothorax that every emergency physician or intensivist must master. Particularly in the preclinical setting, indication must be restricted to urgent cases, but in these cases chest decompression must be executed without delay, even in subpar circumstances. The methods available are needle decompression or thoracentesis via mini-thoracotomy with or without insertion of a chest tube in the midclavicular line of the 2nd/3rd intercostal space (Monaldi-position) or in the anterior to mid-axillary line of the 4th/5th intercostal space (Bülau-position). Needle decompression is quick and does not require much material, but should be regarded as a temporary measure. Due to insufficient length of the usual 14-gauge intravenous catheters, the pleural cavity cannot be reached in a considerable percentage of patients. In the case of mini-thoracotomy, one must be cautious not to penetrate the chest inferior of the mammillary level, to employ blunt dissection techniques, to clearly identify the pleural space with a finger and not to use a trocar. In extremely urgent cases opening the pleural membrane by thoracostomy without inserting a chest tube is sufficient in mechanically ventilated patients. Complications are common and mainly include ectopic positions, which can jeopardise effectiveness of the procedure, sometimes fatal injuries to adjacent intrathoracic or - in case of too inferior placement - intraabdominal organs as well as haemorrhage or infections. By respecting the basic rules for safe chest decompression many of these complications should be avoidable.

How prepared are UK medical graduates for practice? A rapid review of the literature 2009-2014

OBJECTIVE

To understand how prepared UK medical graduates are for practice and the effectiveness of workplace transition interventions.

DESIGN

A rapid review of the literature (registration #CRD42013005305).

DATA SOURCES

Nine major databases (and key websites) were searched in two timeframes (July-September 2013; updated May-June 2014): CINAHL, Embase, Educational Resources Information Centre, Health Management Information Consortium, MEDLINE, MEDLINE in Process, PsycINFO, Scopus and Web of Knowledge.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Primary research or studies reporting UK medical graduates' preparedness between 2009 and 2014: manuscripts in English; all study types; participants who are final-year medical students, medical graduates, clinical educators, patients or NHS employers and all outcome measures.

DATA EXTRACTION

At time 1, three researchers screened manuscripts (for duplicates, exclusion/inclusion criteria and quality). Remaining 81 manuscripts were coded. At time 2, one researcher repeated the process for 2013-2014 (adding six manuscripts). Data were analysed using a narrative synthesis and mapped against Tomorrow's Doctors (2009) graduate outcomes.

RESULTS

Most studies comprised junior doctors' self-reports (65/87, 75%), few defined preparedness and a programmatic approach was lacking. Six themes were highlighted: individual skills/knowledge, interactional competence, systemic/technological competence, personal preparedness, demographic factors and transitional interventions. Graduates appear prepared for history taking, physical examinations and some clinical skills, but unprepared for other aspects, including prescribing, clinical reasoning/diagnoses, emergency management, multidisciplinary team-working, handover, error/safety incidents, understanding ethical/legal issues and ward environment familiarity. Shadowing and induction smooth transition into practice, but there is a paucity of evidence around assistantship efficacy.

CONCLUSIONS

Educational interventions are needed to address areas of unpreparedness (eg, multidisciplinary team-working, prescribing and clinical reasoning). Future research in areas we are unsure about should adopt a programmatic and rigorous approach, with clear definitions of preparedness, multiple stakeholder perspectives along with multisite and longitudinal research designs to achieve a joined-up, systematic, approach to understanding future educational requirements for junior doctors.

Impact of simulation-based training in surgical chest tube insertion on a model of traumatic pneumothorax

Background

Chest tube insertion is required for most cases of traumatic pneumothorax. However, this procedure entails risks of potentially life-threatening complications. A "surgical" approach is widely recommended to minimize these risks. Simulation-based education has previously been used in surgical chest tube insertion, but not been subjected to rigorous evaluation.

Methods

The primary objective was to evaluate the success rate of surgical chest tube insertion in a task trainer (previously published). Secondary objectives were to assess performance with a performance assessment scale (previously designed), to measure the time of insertion, and to seek out a correlation between the learner's status, experience, and performance and success rate. Participants were surveyed for realism of the model and satisfaction; 65 participants (18 residents, 47 senior physicians) were randomized into SIM+ or SIM- groups. Both groups received didactic lessons. The SIM+ group was assigned deliberate practice on the model under supervision. Both groups were assessed on the model 1 month later.

Results

There was no difference between the SIM+ (n = 34) and SIM- (n = 31) groups regarding status (p = 0.44) or previous surgical insertion (p = 0.12). Success rate was 97 % (SIM+) and 58 % (SIM-), p = 0.0002. Performance score was 16.29 ± 1.82 (SIM+) and 11.39 ± 3.67 (SIM-), p = 3.13 × 10^-8. SIM+ presented shorter dissection time than SIM- (p = 0.047), but procedure time was similar (p = 0.71). Status or experience was not correlated with success rate, performance score, procedure time, or dissection time. SIM+ gained more self-confidence, judged the model more realistic, and were more satisfied than SIM-.

Conclusions

Simulation-based education significantly improved the success rate and performance of surgical chest tube insertion on a traumatic pneumothorax model.

Using an Instructional Design Model to Teach Medical Procedures

Educators are often tasked with developing courses and curricula that teach learners how to perform medical procedures. This instruction must provide an optimal, uniform learning experience for all learners. If not well designed, this instruction risks being unstructured, informal, variable amongst learners, or incomplete. This article shows how an instructional design model can help craft courses and curricula to optimize instruction in performing medical procedures. Educators can use this as a guide to developing their own course instruction.

Management of Chest Drains: A National Survey on Surgeons-in-training Experience and Practice

Background:

Chest tube insertion is a simple and sometimes life-saving procedure performed mainly by surgical residents. However with inadequate knowledge and poor expertise, complications may be life threatening.

Objective:

We aimed to determine the level of experience and expertise of resident surgeons in performing tube thoracostomy.

Methodology:

Four tertiary institutions were selected by simple random sampling. A structured questionnaire was administered to 90 residents after obtaining consent.

Results:

The majority of respondents were between 31 and 35 years. About 10% of respondents have not observed or performed tube thoracostomy while 77.8% of respondents performed tube thoracostomy for the first time during residency training. The mean score was 6.2 ± 2.2 and 59.3% of respondents exhibited good experience and practice. Rotation through cardiothoracic surgery had an effect on the score (P = 0.034). About 80.2% always obtained consent while 50.6% always used the blunt technique of insertion. About 61.7% of respondents routinely inserted a chest drain in the Triangle of safety. Only 27.2% of respondents utilized different sizes of chest tubes for different pathologies. Most respondents removed chest drains when the output is <50 mL. Twenty-six respondents (32.1%) always monitored air leak before removal of tubes in cases of pneumothorax. Superficial surgical site infection, tube dislodgement, and tube blockage were the most common complications.

Conclusion:

Many of the surgical resident lack adequate expertise in this lifesaving procedure and they lose the opportunity to learn it as interns. There is a need to stress the need to acquire this skill early, to further educate and evaluate them to avoid complications.

Correlation between ATLS training and junior doctors' anatomical knowledge of intercostal chest drain insertion

OBJECTIVE

To review the ability of junior doctors (JDs) in identifying the correct anatomical site for intercostal chest drain insertion and whether prior Advanced Trauma Life Support (ATLS) training influences this.

DESIGN

We performed a prospective, observational study using a structured survey and asked a group of JDs (postgraduate year 1 [PGY1] or year 2 [PGY2]) to indicate on a photograph the exact preferred site for intercostal chest drain insertion.

SETTING

This study was conducted in a large metropolitan university hospital in South Africa.

RESULTS

A total of 152 JDs participated in the study. Among them, 63 (41%) were men, and the mean age was 24 years. There were 90 (59%) PGY1 doctors and 62 (41%) PGY2 doctors. Overall, 28% (42/152) of all JDs correctly identified the site that was located within the accepted safe triangle. A significantly higher proportion of PGY2 doctors selected the correct site when compared with PGY1 doctors (39% vs 20%, p = 0.026). Those who had prior ATLS provider training were 6.8 times more likely to be able to identify the correct site (RR = 6.8, 95% CI: 3.7-12.5).

CONCLUSIONS

Most of the JDs do not have sufficient anatomical knowledge to identify the safe insertion site for intercostal chest drain. Those who had undergone ATLS training were more likely to be able to identify the safe insertion site.

An audit of the complications of intercostal chest drain insertion in a high volume trauma service in South Africa

INTRODUCTION

Intercostal chest drain (ICD) insertion is a commonly performed procedure in trauma and may be associated with significant morbidity.

METHODS

This was a retrospective review of ICD complications in a major trauma service in South Africa over a four-year period from January 2010 to December 2013.

RESULTS

A total of 1,050 ICDs were inserted in 1,006 patients, of which 91% were male. The median patient age was 24 years (interquartile range [IQR]: 20-29 years). There were 962 patients with unilateral ICDs and 44 with bilateral ICDs. Seventy-five per cent (758/1,006) sustained penetrating trauma and the remaining 25% (248/1006) sustained blunt trauma. Indications for ICD insertion were: haemopneumothorax (n=338), haemothorax (n=314), simple pneumothorax (n=265), tension pneumothorax (n=79) and open pneumothorax (n=54). Overall, 203 ICDs (19%) were associated with complications: 18% (36/203) were kinked, 18% (36/203) were inserted subcutaneously, 13% (27/203) were too shallow and in 7% (14/203) there was inadequate fixation resulting in dislodgement. Four patients (2%) sustained visceral injuries and two sustained vascular injuries. Forty-one per cent (83/203) were inserted outside the 'triangle of safety' but without visceral or vascular injuries. One patient had the ICD inserted on the wrong side. Junior doctors inserted 798 ICDs (76%) while senior doctors inserted 252 (24%). Junior doctors had a significantly higher complication rate (24%) compared with senior doctors (5%) (p<0.001). There was no mortality as a direct result of ICD insertion. </sec> Conclusions ICD insertion is associated with a high rate of complications. These complications are significantly higher when junior doctors perform the procedure. A multifaceted quality improvement programme is needed to improve the situation.

Identifying the site for intercostal catheter insertion in the emergency department: is clinical examination reliable?

OBJECTIVE

To determine whether ED doctors, comprising both consultants and registrars, can accurately identify the 4th or 5th intercostal space (ICS), commonly used for intercostal catheter insertion.

METHODS

An observational study was designed using a sample of ED doctors applying their clinical skills to a convenience sample of patients reflecting a heterogeneous mix of ED patients. Patients already receiving a CXR in our ED were examined by a registrar or consultant who placed a radiopaque marker on the patients' chest wall over the site they determined to be the 4th or 5th ICS. Consultant radiologists reported the marker's position from postero-anterior projection CXRs, and results were analysed comparing consultants with registrars, right to left hemithoraces and male to female patients.

RESULTS

ED doctors participating in the present study placed the marker over the 4th or 5th ICS 36.2% of the time, with no significant difference between consultant and registrar groups, nor right or left hemithoraces. Accuracy was improved in female patients compared with male patients.

CONCLUSION

Emergency registrars and consultants sampled from a regional ED appeared unable to reliably identify the 4th or 5th ICS, as evidenced by marker position, in a heterogeneous patient population.

Indications and complications of tube thoracostomy with improvised underwater seal bottles

Background:

Tube thoracostomy is a lifesaving and frequently performed procedure in hospitals where the expertise and necessary tools are available. Where the ideal drainage receptacle is unavailable, the underwater seal device can be improvised with bottled water plastic can especially in emergency situations.

Aims and Objectives:

To determine the frequencies of the various indications and complications of tube thoracostomy with improvised underwater seal.

Materials and Methods:

A cross-sectional study with a structured proforma was used for assessment over a 3-year period (May 2010-April 2013). The proforma was filled at the time of the procedure by the performing surgeon and patients were followed up with serial chest X-rays until certified cured. A 1.5 L bottled water container was used as the underwater seal receptacle. The data was analysed with SPSS 15 software program.

Results:

A total of 167 patients were managed. There were 106 (63.5%) males and 61 (36.5%) females. The mean age was 34.85 ± 16.72 with a range of 1-80 years. The most frequent indication was for malignant/paramalignant effusion, 46 (27.5%). Others were trauma, 44 (26.3%), Parapneumonic effusion, 20 (12%), postthoracotomy 14 (8.4%), empyema thoracis 12 (7.2%), heart disease and tuberculous effusion 11 (6.6%) each, pneumothorax 8 (4.8%) and misdiagnosis 1 (0.6%). A hundred and one (60.5%) of the procedures were performed by registrars, 41 (24.6%) by consultants, house officers 15 (9%) and senior registrars 10 (6%). The overall complication rate was 16.8% with the more frequent complications been empyema (5.6%) and pneumothorax (3.6%). The average duration of tube placement was 13.02 ± 12.362 days and range of 1-110 days.

Conclusion:

Tube thoracostomy can be a relatively safe procedure with acceptable complication rates even with improvised underwater seal drainage bottles.

The spectrum of visceral injuries secondary to misplaced intercostal chest drains: experience from a high volume trauma service in South Africa

INTRODUCTION

Iatrogenic visceral injuries (IVI) secondary to the insertion of an intercostal chest drain (ICD) are well documented, but are usually confined to case reports and small series.

MATERIALS AND METHODS

We reviewed our experience with 53 consecutive patients over a insertion seven year period who sustained an IVI secondary to an ICD and describe the spectrum of injuries and clinical outcome in a high volume trauma service in South Africa.

RESULTS

A total of 53 ICDs were inserted in 53 patients, 83% (44/53) of which were on the left side, and 17% (9/53) on the right side. 92% (49/53) of the patients were males and the mean age for all patients was 24 (±8) years. 85% of the patients were referred from rural hospitals, the remaining 15% were treated initially at our institution. A trocar was used in 75% (40/53) of patients and in 9% (5/53), a trocar was not used, 58 organ injuries occurred in 53 patients. 92% (49/53) of patients sustained a single organ injury and 4 sustained multiple injuries. The three most common injuries were: diaphragm (36%, 21/53), gastric (22%, 13/53), and pulmonary (12%, 7/53). Other injuries were: 6 (10%) spleen, 4 (7%) liver, 2 (3%) colon and 1 (2%) kidney. Three (5%) sustained an injury to the intercostal artery and one (2%) sustained a pulmonary artery injury. 39 patients (74%) required operative interventions which included laparoscopy: 20 (51%), laparotomy: 8 (21%), thoracotomy: 8 (21%), VAT: 3 (8%). A total of 28 patients (53%) developed further complications: 13 wound sepsis, 7 pneumonia, 6 empyema, 2 ARDS. and 15% (8/53) required intensive care admission. The mean length of hospital stay was 7 (±4) days.

CONCLUSIONS

IVI is associated with significant morbidity, with diaphragmatic, gastric and pulmonary injuries being the most common. The majority were inserted in the rural hospitals and were associated with use of a trochar, Level of evidence: III, Study type: Retrospective study.

An innovative nonanimal simulation trainer for chest tube insertion in neonates

BACKGROUND AND OBJECTIVE

Competence in the chest tube insertion procedure is vital for practitioners who take care of critically ill infants. The use of animals for training is discouraged, and there are no realistic simulation models available for the neonatal chest tube insertion procedure. The objective of this study was to assess the effectiveness of teaching the chest tube insertion procedure by using an easily constructed, nonanimal simulation model.

METHODS

An inexpensive infant chest tube insertion model was developed by using simple hardware. A prospective cohort study with pre-posttest intervention design was conducted with pediatric and combined internal medicine-pediatrics residents. Residents completed a questionnaire about their previous experience of chest tube insertion, knowledge, self-evaluation of knowledge, comfort, and skills; pre, post, and a month after an individualized education session and demonstration of the procedure on the model. Clinical skills were assessed by using a 32-point scoring system when residents performed the procedure on the model immediately after training and a month later.

RESULTS

All residents had significant improvement in knowledge and self-evaluation of knowledge, comfort, and skills scores after the education session and training on the model and this improvement was retained after 1 month (P < .001). Clinical skills scores decreased slightly 1 month after training (P = .08). Scores were not significantly different between the levels of trainees.

CONCLUSIONS

An educational intervention using an easily constructed and inexpensive chest tube insertion model is effective in improving knowledge, comfort, and skills in trainees. The model can be used repeatedly to maintain proficiency.

Spontaneous recovery of ventilator-associated pneumothorax

BACKGROUND

The usual management of ventilator-associated pneumothorax (VPX) is tube thoracostomy. However, this recommendation is based on tradition rather than on solid evidence. Although it has been applied successfully to other types of pneumothoraces, observation has not been used in the management of VPX.

OBJECTIVES

In this study, we investigated whether observation is a valid treatment strategy for VPX.

METHODS

We retrospectively analyzed data of 471 patients with VPX (2003-2010) and found that 27 did not receive tube thoracostomy. Most of those patients (89%) had documented do-not-resuscitate orders and had refused tube thoracostomy. For comparison, 54 patients with tube thoracostomy, matched by age and do-not-resuscitate status, were chosen as controls. Among patients without tube thoracostomy, we compared attribute differences between those recovered and those not recovered.

RESULTS

Thirteen patients (48%) without tube thoracostomy experienced spontaneous recovery of their pneumothoraces. This rate of chest tube-free recovery was higher than that of patients with tube thoracostomy (48 vs. 17%; p = 0.003). The patients did not differ in in-hospital mortality rate, time to ventilator discontinuation or survival. By univariate logistic regression, spontaneous recovery was associated with VPX caused by needle puncture, lack of respiratory distress, large tidal volume and low oxygen requirement following pneumothorax, as well as by physician recommendation against intubation.

CONCLUSION

Observation under physician surveillance is an effective option of managing many VPXs, especially those caused by needle puncture, when patients are not in respiratory distress or when patients have acceptable tidal volumes and oxygen requirements following pneumothorax.

Imaging review of procedural and periprocedural complications of central venous lines, percutaneous intrathoracic drains, and nasogastric tubes

Placements of central venous lines (CVC), percutaneous intrathoracic drains (ITDs), and nasogastric tubes (NGTs) are some of the most common interventional procedures performed on patients that are unconscious and in almost all intensive care/high dependency patients in one form or the other. These are standard procedures within the remit of physicians, and other trained health professionals. Procedural complications may occur in 7%–15% of patients depending upon the intervention and experience of the operator. Most complications are minor, but other serious complications may add significantly to morbidity and even mortality of already compromised patients. Imaging findings are the key to the detection of misplaced lines, and tubes and their prompt recognition are vital to avoid harm to the patient. It is, therefore, pertinent that healthcare professionals who perform these procedures are familiar with imaging complications of these procedures. Here, we present the imaging characteristics of procedural complications.

Hazards of tube thoracostomy in patients on a ventilator

A patient with post-pneumonia empyema complicated by type-2 respiratory failure required mechanical ventilation as part of his therapy. A pneumothorax was noted on his chest radiograph. This was treated with an intercostal chest drain (ICD). Unfortunately, he was still hypoxic, his subcutaneous emphysema was worsening and the ICD was bubbling. A computed tomography (CT) scan of chest demonstrated that the ICD has penetrated the right upper lobe parenchyma. A new ICD was inserted and the previous one was removed. Although both hypoxia and subcutaneous emphysema improved, the patient chronically remained on mechanical ventilation.