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| CASE REPORT |
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| Year : 2021 | Volume
: 10
| Issue : 2 | Page : 124-126 |
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Ventral chest tube placement in a neonate for pneumothorax: An alternative and effective approach
Fazal Nouman Wahid
Department of Pediatric Surgery, King Saud Medical City, Riyadh, Saudi Arabia
| Date of Submission | 20-Sep-2020 |
| Date of Decision | 03-Dec-2020 |
| Date of Acceptance | 16-Dec-2020 |
| Date of Web Publication | 15-May-2021 |
Correspondence Address:
Fazal Nouman Wahid
Department of Pediatric Surgery, King Saud Medical City, Al Imam Turki Ibn Abdullah Ibn Muhammad, Ulaishah, Riyadh 12746
Saudi Arabia
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jcn.jcn_152_20
We present the case of a newborn baby who has developed bilateral pneumothorax treated with ventral chest tube placement after the failure of resolution of the pneumothorax by traditional lateral approach multiple times. An old but yet forgotten approach will be discussed.
Keywords: Neonates, pneumothorax, ventral chest tube
How to cite this article:
Wahid FN. Ventral chest tube placement in a neonate for pneumothorax: An alternative and effective approach. J Clin Neonatol 2021;10:124-6 |
| Introduction | |  |
Neonatal pneumothorax (NP) is a life-threatening condition associated with a high incidence of morbidity and mortality.[1] Its incidence in the neonatal intensive care unit is reported as 1%–2% and demands prompt management.[2],[3] The rate of occurrence can increase up to 30% in patients who have an underlying lung disease, for example, meconium aspiration syndrome, or who need mechanical ventilation at birth.[2] Mortality rates have varied from 20% to 38%.[4] The early diagnosis and treatment of NP are vital to avoid complications and reduce morbidity and mortality.[3] It is generally considered as a complication of resuscitation, or mechanical ventilation, as a barotrauma or volume trauma.
Treatment often includes prompt placement of chest tubes, thus diminishing acute distress, permanent damage, or death.[1],[5],[6] We became aware of a significant number of instances in which the pneumothorax was not effectively evacuated by the chest tubes placed in a traditional way through the lateral chest wall due to misplacement posteriorly requiring readjustment and sometimes multiple tube placement.
We are presenting an alternative and effective approach (ventral chest tube placement) in treating pneumothorax. In ventral approach, we place the chest tubes in the third intercostal space lateral to the midclavicular line to minimize the chances of the tube being misplaced posteriorly. This approach is old but has been either forgotten or not familiar to clinicians.
| Case Report | | |
A full-term newborn baby boy delivered flat at another hospital with an APGAR score of 2, 3, and 5 at 1, 5, and 10 min, respectively. Cardiopulmonary resuscitation was done for 20 min, and the baby was intubated and ventilated. Chest roentgenogram done showed bilateral pneumothorax, and bilateral chest tubes were placed. Afterward, the baby was transferred to our hospital. The baby was hemodynamically stable on mechanical ventilation. Both chest tubes were in place, and upon resolution of the left pneumothorax, the left chest tube was removed. There was re-accumulation of the right pneumothorax, and he has developed subcutaneous emphysema as well despite having a chest tube in place. The right chest tube was put on negative suction without improvement in pneumothorax and needed replacement of the chest tube.
After a day, he again developed right pneumothorax and needed a second chest tube [Figure 1]. Later, one chest tube was removed, but after 6 days, he again developed pneumothorax despite having a chest tube in place. Crosstable roentgenogram confirmed misplacement of the tube posteriorly [Figure 2], so the second tube was again placed. He kept on re-accumulating right pneumothorax four times despite having chest tubes in place and needed replacement and reinsertion of chest tubes over a period of 2 weeks. All the chest tubes were placed through the traditional lateral approach. At this point, a pediatric surgeon was involved and an 8 Fr chest tube was placed ventrally in the third intercostal space slightly lateral to the midclavicular line [Figure 3]. The ventral chest tube was functioning with good oscillation and draining pneumothorax. Sequentially, the lateral chest tubes were removed. We gradually weaned the ventral chest tube off suction and later removed the tube with no more re-accumulation of pneumothorax. | Figure 2: Crosstable roentgenogram showing misplacement of chest tube posteriorly (red arrow)
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 | Figure 3: Ventral chest tube placement just lateral to the midclavicular line in the third intercostal space (red arrow)
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| Discussion | | |
When a pneumothorax occurs, air rises to the anterior and apical pleural space. With a progressively larger pneumothorax, the air then accumulates laterally and posteriorly. With increasing tension, the lung becomes compressed; the mediastinum shifts to the contralateral side. Thus, a chest tube lying posteriorly to the lung not only has less adjacent air to evacuate, but also lung tissue may impinge on its end or side holes and completely or partially obstruct the tube. As a general rule, chest tubes placed for pneumothorax should be directed anteriorly and apically, however, chest tubes placed for hemothorax/hydrothorax should be directed posteriorly and basally.
One of the most common reasons associated with ineffective pneumothorax evacuation is that a chest tube lies posteriorly. The failure rate due to malposition is reported to be 11.2% (5.4%–21%).[7] There are also reports of malposition rates of 25%–30%.[8],[9]
Allent et al.[10] in 1981 published the results of superior approach versus lateral approach chest tube placement in neonates and reported superior approach better. They reported 42% of ineffective chest tube placement and the majority of them ineffective because they were lying posteriorly. They reported a failure rate of 35% when placed through a lateral approach. Moreover, to the best of our knowledge, this is the only study done in neonates discussing this approach. The superior/ventral approach has been forgotten and not many clinicians are aware or familiar with this approach in treating pneumothorax. This report is to emphasize the use of the ventral approach [Figure 4] in treating pneumothorax if facing difficulties with a lateral approach as the chances of a tube being placed posteriorly with this approach is far less compared to lateral approach. It would be difficult to direct the tube cranially through a ventral approach but that is not needed and just placing the tube high up (third intercostal space) in a pleural cavity is sufficient to drain pneumothorax. There might be a chance of kinking of a tube being placed through the anterior chest wall in older children. However, that does not seem to be a concern in neonates because of the thin chest wall. There are also right angle chest tubes available to overcome the problem of kinking which are best for being placed ventrally. | Figure 4: Sites for chest tube insertion: Ventral approach through the third intercostal space just lateral to the midclavicular line and lateral approach through the fourth or fifth intercostal space in the lateral chest wall
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Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
| Conclusion | | |
Ventral chest tube placement is an efficient and better alternative to traditional lateral chest tube placement in treating pneumothorax as chances of misplacement of a tube posteriorly are far less compared to lateral chest tube placement.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 6. | Moessinger AC, Driscoll JM Jr., Wigger HJ. High incidence of lung perforation by chest tube in neonatal pneumothorax. J Pediatr 1978;92:635-7. |
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| 8. | Baldt MM, Bankier AA, Germann PS, Pöschl GP, Skrbensky GT, Herold CJ. Complications after emergency tube thoracostomy: Assessment with CT. Radiology 1995;195:539-43. |
| 9. | Bailey RC. Complications of tube thoracostomy in trauma. J Accid Emerg Med 2000;17:111-4. |
| 10. | Allen RW Jr., Jung AL, Lester PD. Effectiveness of chest tube evacuation of pneumothorax in neonates. J Pediatr 1981;99:4. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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