Q: 58 year old male is admitted to ICU overnight with exacerbation of COPD. Patient required intubation. Patient CXR next morning showed pneumothorax with progressively worsening desaturation. Immediately chest tube is inserted but didn't bring any relief and patient remained hypoxic. CXR showed no resolution of CXR. Malposition of chest tube, either intrafissural or intraparenchymal is suspected as there is no air leak. What should be the next step?

A) Remove chest tube immediately and repeat CXR
B) Call Thoracic surgery
C) Increase PEEP on ventilator for desaturation
D) Extubate and reintubate patient
E) Increase suction on chest tube from -20 to -40


Answer: B

About 25% of chest tubes may be malpositioned on blind insertion. Objective of above question is to emphasize that in such scenarios inserted chest tube should not be removed as it may cause further harm by worsening pneumothorax. Thoracic surgery should be called to insert new chest tube and once it is working, old chest tube can be removed with caution. Ideally, CT scan of chest should be performed before removal of previous chest tube given patient is clinically stable.

C) is wrong as increased PEEP may harm by causing further increase in pneumothorax.

D) is crazy! No! you never do that!

E) can be tried under close watch but it may not solve the original problem.


Reference: 

 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.