Aim More Toward the Bed than the Head: A Proof-of-Concept Pilot Study on a Simple Technique for Keeping Trauma Thoracostomy Tubes Out of Lung Fissures.

Introduction: Tube thoracostomy (TT) is used to drain the pleural cavity in the setting of both traumatic and nontraumatic pathologies. Literature has shown that inappropriate tube positioning occurs in 30% of patients, including TTs placed within the fissure, which may result in further interventions in these patients. Our goal was to compare the rates of TT placed into a lung fissure in a controlled model using a simple approach to direct the tube more toward the bed than the patient's head at the time of placement to validate further investigations of the clinical applicability of this technique.

Methods: We performed 650 tube thoracostomies in 3 separate cadaver torsos with tracheal intubation and bag valve mask approximating a 50% pneumothorax. TTs were performed by experienced clinicians using a "more toward the head" direction and a "more toward the bed" direction while varying other factors, including side of the chest, tube size, and location on the chest wall, followed by lung re-expansion to better evaluate each approach in different common clinical scenarios. A power analysis was performed for our primary outcome of tube placement in a lung fissure by direction, not for any additional variables. Multivariate analysis was used to determine whether the "head" or "bed" direction was more likely to result in tube placement in a fissure when controlling for other changes.

Results: A total of 650 TTs were placed in 3 cadavers by 2 experienced performers. The overall rate of tube placement in a fissure was 41% using the "head" direction and 13% using the "bed" direction. On multivariate analysis, the "bed" direction also was shown to have significantly decreased tube placement in a lung fissure when controlling for side, tube size, and location (P  <  0.01; odds ratio 0.22; 95% CI, 0.14 - 0.33).

Conclusions: Aiming more toward the bed than toward the head during TT placement is associated with a significantly decreased chance of placing the TT within a lung fissure in this highly controlled cadaveric proof-of-concept model. This technique requires no changes to standard TT placement set-up, time, cost, or equipment. We propose that it warrants further investigation as a potential intervention to decrease malpositioned tubes.