How you evaluate these traditional teachings of directing ICD tubes towards apex of lung in pneumothorax and base in hydro/hemothorax? Are they still relevant?
It is not a must to direct chest tube to the base in pleural effusions or hemothox, as the tube would drain where ever you place it in pleural cavity so long as there are no loculations in the pleural cavity and the underwater seal drainage helps by providing requisite negative suction. However chest tube should always be directed to apex of the chest cavity because,:occasionally the chest tube gets sealed off from the apical portion by the expanding lung resulting in trapping of a pocket of air in the apical spacespace. This situation either demands a new fine bore needlle aspiration via second IC space, an additional chest tube, or accept it and wait for its natural resolution if small.
I think it is still relevant where we position chest tubes, especially when performed blindly. Also important to have them exiting anterior to the mid-axillary line so the patient does not have the discomfort of lying on the tubes.
In our experience it is important to direct the chest tubes to the apex in pneumothorax as air tend to locate apically. Otherwise, once the lung starts to expend, the chest tube may become isolated preventing draining the air. In case of an hemothorax, as long as there are no clots the fluid will be drained by capillarity, so it won´t be so important were the chest tube is located, however the surgeon should try to orientate it backwards and no so high in the chest. In a prospective study, we found that one of the risk factors statistically significant for complications was the misplacement of chest tubes, ie, for example tubes placed to low in the chest. (Factores de riesgo para el desarrollo de complicaciones en las toracostomías cerradas por trauma. Panam J Trauma Crit Care Emerg Surg 2013;2;69-73
