Thoraxdrainage beim Thoraxtrauma – Empfehlungen der interdisziplinären Arbeitsgemeinschaft Thoraxtrauma der Deutschen Gesellschaft für Thoraxchirurgie (DGT) und der Deutschen Gesellschaft für Unfallchirurgie (DGU)

Zusammenfassung

Die Anlage einer Thoraxdrainage ist zwar grundsätzlich eine einfache, aber oft lebensrettende Notfallmaßnahme. Trotz der Häufigkeit der Prozedur zeigen sich jedoch Unsicherheiten im Umgang mit daraus resultierend hoher Komplikationsrate. Für alle Beteiligten stellt sowohl die Diagnostik, die Indikationsstellung und die Anlage selbst, wie auch das nachfolgende Management der Drainage eine wiederkehrende Herausforderung dar. Die Unter-AG Lungenverletzung der interdisziplinären AG (Arbeitsgemeinschaft) Thoraxtrauma der Deutschen Gesellschaft für Thoraxchirurgie (DGT) und Deutschen Gesellschaft für Unfallchirurgie (DGU) erarbeitete konsensuelle Behandlungsempfehlungen basierend auf einer Systematic-Review-like Literaturrecherche (MEDLINE via PubMed von 1997 bis 2022). Mit der aktuell vorliegenden Recherche konnten 60 repräsentative Arbeiten identifiziert werden, die Empfehlungen zulassen, jedoch meist nur einen niedrigen Evidenzgrad aufweisen. Die Empfehlungen sind nicht mit Evidenzgraden hinterlegt, sondern haben zunächst Konsenscharakter.

Für den instabilen Patienten mit Thoraxtrauma stellt die Thoraxdrainage das Mittel der Wahl zur Entlastung eines Pneumothorax oder Hämatothorax dar. Beim Spannungspneumothorax sollte eine initiale Entlastungspunktion mit einer mindestens 5 cm langen Kanüle, gefolgt von der Anlage einer Thoraxdrainage erfolgen. Diagnostik und Beurteilung des Patienten sollten primär und im Verlauf durch die klinische Untersuchung, eine Röntgenuntersuchung des Thorax sowie eine Thoraxsonografie erfolgen, Goldstandard der Diagnostik ist jedoch die Computertomografie (CT). Beim kreislaufstabilen Patienten soll eine kleinlumige Drainage (z. B. 14 Charrière [Charr]) verwendet werden, instabile Patienten sollten eine großlumige Drainage erhalten. Thoraxdrainagen besitzen eine hohe Komplikationsrate zwischen 5% und 25%. Häufig sind insbesondere Fehlpositionierungen im Rahmen der Anlage. Eine Fehllage kann jedoch meist nur im CT sicher erkannt oder ausgeschlossen werden. Eine Therapie sollte mit mildem Sog erfolgen, ein Abklemmen vor Entfernung ist nicht zielführend. Der Drainagenzug kann sowohl am Ende der Inspiration oder Exspiration sicher erfolgen. Zur Verringerung der hohen Komplikationsrate sollte vermehrt der Fokus auf die Ausbildung und das Training der Anwender gelegt werden.

Abstract

For unstable patients with chest trauma, the chest tube is the method of choice for the treatment of a relevant pneumothorax or haemothorax. In the case of a tension pneumothorax, needle decompression with a cannula of at least 5 cm length should be performed, directly followed by the insertion of a chest tube. The evaluation of the patient should be performed primarily with a clinical examination, a chest X-ray and sonography, but the gold standard of diagnostic testing is computed tomography (CT).

A small-bore chest tube (e.g. 14 French) should be used in stable patients, while unstable patients should receive a large-bore drain (24 French or larger). Insertion of chest drains has a high complication rate of between 5% and 25%, and incorrect positioning of the tube is the most common complication. However, incorrect positioning can usually only be reliably detected or ruled out with a CT scan, and chest X-rays proofed to be insufficient to answer this question. Therapy should be carried out with mild suction of approximately 20 cmH₂O, and clamping the chest tube before removal showed no beneficial effect. The removal of drains can be safely performed, either at the end of inspiration or at the end of expiration. In order to reduce the high complication rate, in the future the focus should be more on the education and training of medical staff members.

Schlüsselwörter

Thoraxdrainage - Thoraxchirurgie - Thoraxtrauma

Keywords

chest tube - thoracic surgery - thoracic trauma - chest drain

Publication History

Received: 15 May 2022

Accepted after revision: 04 November 2022

Article published online:
27 February 2023

• Literatur

• 1 Wells BJ, Roberts DJ, Grondin S. et al. To drain or not to drain? Predictors of tube thoracostomy insertion and outcomes associated with drainage of traumatic hemothoraces. Injury 2015; 46: 1743-1748 DOI: 10.1016/j.injury.2015.04.032. (PMID: 25983221)
• 2 Molnar TF. Thoracic Trauma: Which Chest Tube When and Where?. Thorac Surg Clin 2017; 27: 13-23 DOI: 10.1016/j.thorsurg.2016.08.003. (PMID: 27865322)
• 3 Bertoglio P, Guerrera F, Viti A. et al. Chest drain and thoracotomy for chest trauma. J Thorac Dis 2019; 11: S186-S191 DOI: 10.21037/jtd.2019.01.53. (PMID: 30906584)
• 4 Oxford Centre for Evidence-Based Medicine (OCEBM), OCEBM Levels of Evidence Working Group. The Oxford 2011 Levels of Evidence. Accessed November 19, 2022 at: https://www.cebm.ox.ac.uk/resources/levels-of-evidence/ocebm-levels-of-evidence
• 5 Waydhas C, Sauerland S. Thoraxtrauma und Thoraxdrainage: Diagnostik und Therapie. Ein systematisches Review. Teil 1: Diagnostik. Notfall & Rettungsmedizin 2003; 6: 541-548 DOI: 10.1007/s10049-003-0607-9.
• 6 Waydhas C, Sauerland S. Thoraxtrauma und Thoraxdrainage: Diagnostik und Therapie. Ein systematisches Review. Teil 2: Therapie. Notfall & Rettungsmedizin 2003; 6: 627-639 DOI: 10.1007/s10049-003-0614-x.
• 7 Aylwin CJ, Brohi K, Davies GD. et al. Pre-hospital and in-hospital thoracostomy: indications and complications. Ann R Coll Surg Engl 2008; 90: 54-57 DOI: 10.1308/003588408×242286. (PMID: 18201502)
• 8 High K, Brywczynski J, Guillamondegui O. Safety and Efficacy of Thoracostomy in the Air Medical Environment. Air Med J 2016; 35: 227-230 DOI: 10.1016/j.amj.2016.04.002. (PMID: 27393758)
• 9 Chung MH, Hsiao CY, Nian NS. et al. The Benefit of Ultrasound in Deciding Between Tube Thoracostomy and Observative Management in Hemothorax Resulting from Blunt Chest Trauma. World J Surg 2018; 42: 2054-2060 DOI: 10.1007/s00268-017-4417-5. (PMID: 29305713)
• 10 McGillicuddy D, Rosen P. Diagnostic dilemmas and current controversies in blunt chest trauma. Emerg Med Clin North Am 2007; 25: 695-711 DOI: 10.1016/j.emc.2007.06.004. (PMID: 17826213)
• 11 Zhang M, Teo LT, Goh MH. et al. Occult pneumothorax in blunt trauma: is there a need for tube thoracostomy?. Eur J Trauma Emerg Surg 2016; 42: 785-790 DOI: 10.1007/s00068-016-0645-x. (PMID: 26860113)
• 12 Wilson H, Ellsmere J, Tallon J. et al. Occult pneumothorax in the blunt trauma patient: tube thoracostomy or observation?. Injury 2009; 40: 928-931 DOI: 10.1016/j.injury.2009.04.005. (PMID: 19539280)
• 13 Beattie G, Cohan CM, Tang A. et al. Observational management of penetrating occult pneumothoraces: Outcomes and risk factors for interval tube thoracostomy placement. J Trauma Acute Care Surg 2022; 92: 177-184 DOI: 10.1097/ta.0000000000003415. (PMID: 34538828)
• 14 Koryllos A, Eggeling S, Schega O. et al. [Delphi Expert Consensus of the German Thoracic Surgery Society on the Management of Chest Tube Drainage]. Zentralbl Chir 2020; 145: 99-107 DOI: 10.1055/a-0963-0404. (PMID: 31394582)
• 15 Schreyer C, Schwab R. [Management of thoracic trauma and intrathoracic injuries]. Chirurg 2020; 91: 517-530 DOI: 10.1007/s00104-020-01176-w. (PMID: 32377762)
• 16 Hefny AF, Kunhivalappil FT, Matev N. et al. Management of computed tomography-detected pneumothorax in patients with blunt trauma: experience from a community-based hospital. Singapore Med J 2018; 59: 150-154 DOI: 10.11622/smedj.2017074. (PMID: 28741012)
• 17 Yadav K, Jalili M, Zehtabchi S. Management of traumatic occult pneumothorax. Resuscitation 2010; 81: 1063-1068 DOI: 10.1016/j.resuscitation.2010.04.030. (PMID: 20619952)
• 18 Bauman ZM, Kulvatunyou N, Joseph B. et al. Randomized Clinical Trial of 14-French (14F) Pigtail Catheters versus 28–32F Chest Tubes in the Management of Patients with Traumatic Hemothorax and Hemopneumothorax. World J Surg 2021; 45: 880-886 DOI: 10.1007/s00268-020-05852-0. (PMID: 33415448)
• 19 Inaba K, Lustenberger T, Recinos G. et al. Does size matter? A prospective analysis of 28–32 versus 36–40 French chest tube size in trauma. J Trauma Acute Care Surg 2012; 72: 422-427 DOI: 10.1097/TA.0b013e3182452444.
• 20 Kulvatunyou N, Erickson L, Vijayasekaran A. et al. Randomized clinical trial of pigtail catheter versus chest tube in injured patients with uncomplicated traumatic pneumothorax. Br J Surg 2014; 101: 17-22 DOI: 10.1002/bjs.9377. (PMID: 24375295)
• 21 Tanizaki S, Maeda S, Sera M. et al. Small tube thoracostomy (20–22 Fr) in emergent management of chest trauma. Injury 2017; 48: 1884-1887 DOI: 10.1016/j.injury.2017.06.021. (PMID: 28673640)
• 22 Bauman ZM, Kulvatunyou N, Joseph B. et al. A Prospective Study of 7-Year Experience Using Percutaneous 14-French Pigtail Catheters for Traumatic Hemothorax/Hemopneumothorax at a Level-1 Trauma Center: Size Still Does Not Matter. World J Surg 2018; 42: 107-113 DOI: 10.1007/s00268-017-4168-3. (PMID: 28795207)
• 23 Kulvatunyou N, Bauman ZM, Zein Edine SB. et al. The small (14 Fr) percutaneous catheter (P-CAT) versus large (28–32 Fr) open chest tube for traumatic hemothorax: A multicenter randomized clinical trial. J Trauma Acute Care Surg 2021; 91: 809-813 DOI: 10.1097/ta.0000000000003180. (PMID: 33843831)
• 24 Maezawa T, Yanai M, Huh JY. et al. Effectiveness and safety of small-bore tube thoracostomy (≤ 20 Fr) for chest trauma patients: A retrospective observational study. Am J Emerg Med 2020; 38: 2658-2660 DOI: 10.1016/j.ajem.2020.09.028. (PMID: 33039219)
• 25 Parker MH, Newcomb AB, Liu C. et al. Chest Tube Management Practices by Trauma Surgeons. J Surg Res 2019; 244: 225-230 DOI: 10.1016/j.jss.2019.06.032. (PMID: 31301478)
• 26 Terada T, Nishimura T, Uchida K. et al. How emergency physicians choose chest tube size for traumatic pneumothorax or hemothorax: a comparison between 28Fr and smaller tube. Nagoya J Med Sci 2020; 82: 59-68 DOI: 10.18999/nagjms.82.1.59. (PMID: 32273633)
• 27 Adrales G, Huynh T, Broering B. et al. A thoracostomy tube guideline improves management efficiency in trauma patients. J Trauma 2002; 52: 210-214 DOI: 10.1097/00005373-200202000-00002. (PMID: 11834977)
• 28 Huber-Wagner S, Körner M, Ehrt A. et al. Emergency chest tube placement in trauma care – which approach is preferable?. Resuscitation 2007; 72: 226-233 DOI: 10.1016/j.resuscitation.2006.06.038. (PMID: 17141396)
• 29 Secchi A, Ziegenfuß T. Checkliste Notfallmedizin. 4. Stuttgart: Thieme; 2009
• 30 Kaserer A, Stein P, Simmen HP. et al. Failure rate of prehospital chest decompression after severe thoracic trauma. Am J Emerg Med 2017; 35: 469-474 DOI: 10.1016/j.ajem.2016.11.057. (PMID: 27939518)
• 31 Massarutti D, Trillò G, Berlot G. et al. Simple thoracostomy in prehospital trauma management is safe and effective: a 2-year experience by helicopter emergency medical crews. Eur J Emerg Med 2006; 13: 276-280 DOI: 10.1097/00063110-200610000-00006. (PMID: 16969232)
• 32 Ball CG, Wyrzykowski AD, Kirkpatrick AW. et al. Thoracic needle decompression for tension pneumothorax: clinical correlation with catheter length. Can J Surg 2010; 53: 184-188 (PMID: 20507791)
• 33 Aho JM, Thiels CA, El Khatib MM. et al. Needle thoracostomy: Clinical effectiveness is improved using a longer angiocatheter. J Trauma Acute Care Surg 2016; 80: 272-277 DOI: 10.1097/ta.0000000000000889. (PMID: 26670108)
• 34 Powers WF, Clancy TV, Adams A. et al. Proper catheter selection for needle thoracostomy: a height and weight-based criteria. Injury 2014; 45: 107-111 DOI: 10.1016/j.injury.2013.08.026. (PMID: 24064394)
• 35 Sanchez LD, Straszewski S, Saghir A. et al. Anterior versus lateral needle decompression of tension pneumothorax: comparison by computed tomography chest wall measurement. Acad Emerg Med 2011; 18: 1022-1026 DOI: 10.1111/j.1553-2712.2011.01159.x. (PMID: 21951681)
• 36 Zengerink I, Brink PR, Laupland KB. et al. Needle thoracostomy in the treatment of a tension pneumothorax in trauma patients: what size needle?. J Trauma 2008; 64: 111-114 DOI: 10.1097/01.ta.0000239241.59283.03.
• 37 Dominguez KM, Ekeh AP, Tchorz KM. et al. Is routine tube thoracostomy necessary after prehospital needle decompression for tension pneumothorax?. Am J Surg 2013; 205: 329-332 DOI: 10.1016/j.amjsurg.2013.01.004. (PMID: 23414956)
• 38 Muslim M, Bilal A, Salim M. et al. Tube thorocostomy: management and outcome in patients with penetrating chest trauma. J Ayub Med Coll Abbottabad 2008; 20: 108-111 (PMID: 19999219)
• 39 Ramanathan R, Wolfe LG, Duane TM. Initial suction evacuation of traumatic hemothoraces: a novel approach to decreasing chest tube duration and complications. Am Surg 2012; 78: 883-887 (PMID: 22856496)
• 40 Morales CH, Mejía C, Roldan LA. et al. Negative pleural suction in thoracic trauma patients: A randomized controlled trial. J Trauma Acute Care Surg 2014; 77: 251-255 DOI: 10.1097/ta.0000000000000281. (PMID: 25058250)
• 41 Kong VY, Oosthuizen GV, Clarke DL. What is the yield of routine chest radiography following tube thoracostomy for trauma?. Injury 2015; 46: 45-48 DOI: 10.1016/j.injury.2014.06.015. (PMID: 25062601)
• 42 Schulman CI, Cohn SM, Blackbourne L. et al. How long should you wait for a chest radiograph after placing a chest tube on water seal? A prospective study. J Trauma 2005; 59: 92-95 DOI: 10.1097/01.ta.0000171463.95296.9e.
• 43 Maxwell RA, Campbell DJ, Fabian TC. et al. Use of presumptive antibiotics following tube thoracostomy for traumatic hemopneumothorax in the prevention of empyema and pneumonia--a multi-center trial. J Trauma 2004; 57: 742-748 DOI: 10.1097/01.ta.0000147481.42186.42. (PMID: 15514527)
• 44 Bell RL, Ovadia P, Abdullah F. et al. Chest tube removal: end-inspiration or end-expiration?. J Trauma 2001; 50: 674-677 DOI: 10.1097/00005373-200104000-00013. (PMID: 11303163)
• 45 Martino K, Merrit S, Boyakye K. et al. Prospective randomized trial of thoracostomy removal algorithms. J Trauma 1999; 46: 369-371 DOI: 10.1097/00005373-199903000-00003. (PMID: 10088835)
• 46 Pacanowski JP, Waack ML, Daley BJ. et al. Is routine roentgenography needed after closed tube thoracostomy removal?. J Trauma 2000; 48: 684-688 DOI: 10.1097/00005373-200004000-00016. (PMID: 10780602)
• 47 Goodman MD, Huber NL, Johannigman JA. et al. Omission of routine chest x-ray after chest tube removal is safe in selected trauma patients. Am J Surg 2010; 199: 199-203 DOI: 10.1016/j.amjsurg.2009.03.011. (PMID: 20113700)
• 48 Zonies D, Elterman J, Burns C. et al. Trauma patients are safe to fly 72 hours after tube thoracostomy removal. J Trauma Acute Care Surg 2018; 85: 491-494 DOI: 10.1097/ta.0000000000001976. (PMID: 29782482)
• 49 Pizano LR, Houghton DE, Cohn SM. et al. When should a chest radiograph be obtained after chest tube removal in mechanically ventilated patients? A prospective study. J Trauma 2002; 53: 1073-1077 DOI: 10.1097/00005373-200212000-00008. (PMID: 12478031)
• 50 Rasheed MA, Majeed FA, Ali Shah SZ. et al. Role Of Clamping Tube Thoracostomy Prior To Removal In Non-Cardiac Thoracic Trauma. J Ayub Med Coll Abbottabad 2016; 28: 476-479 (PMID: 28712216)
• 51 Menger R, Telford G, Kim P. et al. Complications following thoracic trauma managed with tube thoracostomy. Injury 2012; 43: 46-50 DOI: 10.1016/j.injury.2011.06.420. (PMID: 21839442)
• 52 Sethuraman KN, Duong D, Mehta S. et al. Complications of tube thoracostomy placement in the emergency department. J Emerg Med 2011; 40: 14-20 DOI: 10.1016/j.jemermed.2008.06.033. (PMID: 19097724)
• 53 Jones CW, Rodriguez RD, Griffin RL. et al. Complications Associated With Placement of Chest Tubes: A Trauma System Perspective. J Surg Res 2019; 239: 98-102 DOI: 10.1016/j.jss.2019.01.012. (PMID: 30825758)
• 54 Kong VY, Oosthuizen GV, Sartorius B. et al. An audit of the complications of intercostal chest drain insertion in a high volume trauma service in South Africa. Ann R Coll Surg Engl 2014; 96: 609-613 DOI: 10.1308/003588414×14055925058599. (PMID: 25350185)
• 55 Gayer G, Rozenman J, Hoffmann C. et al. CT diagnosis of malpositioned chest tubes. Br J Radiol 2000; 73: 786-790 DOI: 10.1259/bjr.73.871.11089474. (PMID: 11089474)
• 56 Landay M, Oliver Q, Estrera A. et al. Lung penetration by thoracostomy tubes: imaging findings on CT. J Thorac Imaging 2006; 21: 197-204 DOI: 10.1097/01.rti.0000213644.57288.2f. (PMID: 16915064)
• 57 Lim KE, Tai SC, Chan CY. et al. Diagnosis of malpositioned chest tubes after emergency tube thoracostomy: is computed tomography more accurate than chest radiograph?. Clin Imaging 2005; 29: 401-405 DOI: 10.1016/j.clinimag.2005.06.032. (PMID: 16274893)
• 58 Matsumoto S, Sekine K, Funabiki T. et al. Chest tube insertion direction: is it always necessary to insert a chest tube posteriorly in primary trauma care?. Am J Emerg Med 2015; 33: 88-91 DOI: 10.1016/j.ajem.2014.10.042. (PMID: 25468216)
• 59 Bailey RC. Complications of tube thoracostomy in trauma. J Accid Emerg Med 2000; 17: 111-114 DOI: 10.1136/emj.17.2.111. (PMID: 10718232)
• 60 Finnegan P, Fitzgerald M, Smit D. et al. Video-tube thoracostomy in trauma resuscitation: A pilot study. Injury 2019; 50: 90-95 DOI: 10.1016/j.injury.2018.08.007. (PMID: 30143233)
• 61 Deneuville M. Morbidity of percutaneous tube thoracostomy in trauma patients. Eur J Cardiothorac Surg 2002; 22: 673-678 DOI: 10.1016/s1010-7940(02)00478-5. (PMID: 12414029)