\\n\\n
Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\\n\\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
\\n"}]',published:!0,mainMedia:{caption:"Highly Cited",originalUrl:"/media/original/117"}},components:[{type:"htmlEditorComponent",content:'IntechOpen is proud to announce that 191 of our authors have made the Clarivate™ Highly Cited Researchers List for 2020, ranking them among the top 1% most-cited.
\n\nThroughout the years, the list has named a total of 261 IntechOpen authors as Highly Cited. Of those researchers, 69 have been featured on the list multiple times.
\n\n\n\nReleased this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\n\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
\n'}],latestNews:[{slug:"intechopen-supports-asapbio-s-new-initiative-publish-your-reviews-20220729",title:"IntechOpen Supports ASAPbio’s New Initiative Publish Your Reviews"},{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"}]},book:{item:{type:"book",id:"147",leadTitle:null,fullTitle:"Biosensors - Emerging Materials and Applications",title:"Biosensors",subtitle:"Emerging Materials and Applications",reviewType:"peer-reviewed",abstract:"A biosensor is a detecting device that combines a transducer with a biologically sensitive and selective component. Biosensors can measure compounds present in the environment, chemical processes, food and human body at low cost if compared with traditional analytical techniques. This book covers a wide range of aspects and issues related to biosensor technology, bringing together researchers from 19 different countries. 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He received his degree as Medical Doctor at Sassari University in 1998 and studied the in vivo Neurochemistry of Parkinson’s Disease using microdialysis and voltammetry under the supervision of Dr. Maddalena Miele. Prof. Serra received his PhD in Pharmacology and in 2001 and he worked as a Postdoctoral Fellow at University College of Dublin and at National University of Maynooth (Ireland) under the direction of Prof. Robert D. O’Neill and Dr. John P. Lowry. 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This has led to the precise management of gynecological problems in the field of infertility, recurrent miscarriages, postmenopausal bleeding, uterine cancer, and menstrual disorders. Although transvaginal ultrasound scanning in 2D and 3D mode are considered useful tools for first line screening, the gap between precise diagnosis before treatment was covered by the introduction of a fine hysteroscope, which provides more accurate information. Nevertheless in most cases operative hysteroscopy substituted the blind technique of dilation and curettage, solely used over the past years.
Office hysteroscopy is a very useful technique for diagnosis and treatment of uterine pathology in an office-based environment (Figure 1). It is directly related to the technological explosion, which during the last years has further evolved and given us the opportunity to perform hysteroscopy without providing general anesthesia or sedation to the patients, due to the narrow width of the latest generation hysteroscopes. This means that after adequate and thorough experience and toward the reduction of the cost and satisfaction of the patients, hysteroscopy in an outpatient environment, called office hysteroscopy, has started to attract the majority of gynecologists.
The aim of this chapter is to familiarize the clinicians in the field of gynecology with the instrumentation and setup, the technique itself, indications, and contraindications for performing office hysteroscopy and finally the advantages for the patient and the clinician who perform this endoscopic approach.
Typical setup for office hysteroscopy in a private office-based practice
There are two different types of hysteroscopes available. The rigid hysteroscopes are composed of two parts, the scope and the outer sheath with a total diameter of 2.9–4 mm (Figure 2, Figure 3). The outer sheath comes with suction and irrigation valves, which allows the inflow and outflow of the distension medium of the uterine cavity and can be mounted on an irrigation-suction device. Further, there is an operating channel from which specifically designed instruments can go through for operative purposes or retrieval of endometrial tissue for biopsy. The advantages are that they are exactly the same as the non-office hysteroscopes, so for a clinician who is experienced in hysteroscopy there is no learning curve, and they can be used without inserting a vaginal speculum (no-touch technique or vaginoscopic approach). Furthermore, they can be used with suction device, while a great variety of instruments are specifically designed for these and the scopes are available in 12, 25, or 30 degrees angular vision. In the disadvantages we need to mention that they come in many parts and also the optics are very thin, from 2 mm in diameter, which makes them very fragile during cleaning and disinfection, while there is an existing risk of uterine perforation due to the rigidity. Finally, they have greater width compared with the flexible hysteroscopes.
Operative hysteroscope for office hysteroscopy
The flexible hysteroscopes (Figure 4) are compact without any additional part, even the light source cable is permanently fixed on these. They do not come with an outer sheath, which means that they lack suction mechanism but there is a working channel, through which flexible instruments can be inserted and used for biopsy and minor surgical procedures. The visual angle is up to 120 degrees due to the flexibility, so there is no external manipulation of the hysteroscope, which can minimize the discomfort of the patient. Cleaning, disinfection, and storage are simpler than the rigid ones. The possible perforation of the uterus is quite non-existing, but on the contrary during insertion the scope might be obstructed by even loose adhesions or endometrial structures such as large polyps or fibroids. In practice, and from our experience, it means that it is preferable to dilate the cervical canal before insertion with a thin dilator. The vaginoscopic approach is more difficult to be performed with a flexible hysteroscope compared to the rigid ones and therefore in all cases the use of a vaginal speculum is needed but on the other hand the use of a tenaculum for straightening the cervical canal is almost never needed, as long as due to the flexibility the scope can easily go through all types of uterus (anteverted, retroverted, etc.). Finally, there is clear evidence that in procedures where flexible hysteroscopes are used patients experience less pain and discomfort [1].
Distal part of an office operative hysteroscope
Flexible hysteroscope of 3.1 mm total diameter
The basic setup in order to perform an office hysteroscopy consists of a camera, a camera control unit connected to a -DVD recording device, a light source, and a monitor, connected exactly the same way as in the operating theater, all of them placed on an equipment cart, or there are also compact devices where all the above mentioned come as a single appliance. An irrigation-suction unit for the distension medium can be used, but for diagnostic purposes a handcuff with a manual air pump can be used for irrigation, around the bottle of the distension medium, as long as for experienced clinicians the whole procedure will last less than 5 minutes and the amount of the distension medium to be used will be less than 200 ml. Additional equipment ready for use can be a dental syringe fitted with a sealed cartridge containing anesthetic solution for cervical local anesthesia and a plastic cervical dilator, a vaginal speculum, sterile gauges, and a forceps in order to control spotting bleeding from the cervix, after injection of local anesthetic, all placed on a secondary equipment cart. The patient is placed on a gynecological chair, in lithotomy position that will allow the clinician to perform manipulations with the hysteroscope without restrictions. It is advised that a flat examination bed is also present in the same room, in case of vasovagal reaction after the end of the procedure. A typical setup is shown in Figure 1. Finally it is advised that a chaperon is present during the procedure, but in terms of assistance the setup described is ideal for a single person to perform.
There is no clear evidence that local anesthesia should be used prior to office hysteroscopy, while results from several studies cannot reach a definite conclusion. Nevertheless in cases of non-vaginoscopic procedures from our experience, we strongly recommend the proposal of cervical local anesthetic, which can possibly lead to less pain experienced by the patients, especially if cervical dilatation is needed, but also gives a feeling of confidence to the patients before getting through the procedure. Moreover, in cases where the use of tenaculum is needed, local cervical anesthesia should be applied [2]. It should be mentioned that use of intracervical or paracervical local anesthesia for preventing vasovagal reactions is not an indication.
Conscious sedation should not be used as it does not contribute to pain control more than local anesthesia and also dangerous complications that may occur cannot be controlled in an office-cased environment [3].
As far as analgesia is concerned, it is recommended that NSAIDS (non-steroidal anti-inflammatory drugs) should be used an hour prior to the procedure for pain relief but the use of opioids should be avoided as they may have adverse effects like nausea, vomiting, and drowsiness [2].
In general the choice for analgesia prior or during the procedure should be decided by the clinician according to the patient’s history, possible vasovagal reaction in the past, the condition of the uterine cervix (nulliparous or multiparous), and the reluctancy of the patient regarding the possible pain that she may experience during the procedure. All the choices should be offered to the patients during the consent procedure.
Office hysteroscopy can be performed with the use of normal saline solution or CO2. It is advisable that the choice of the medium is at the discretion of the clinician. Nevertheless, there seem to be advantages from the use of normal saline as long as it can provide better visibility and clearing out of blood clots and debris, less possible vasovagal reactions (sickness, bradycardia, and hypotension) from the patients, and also the setup is more simple and more practical compared to CO2. Furthermore, the use of normal saline does not offer reduction of pain but can lead to quicker procedures [4,5], but the latter is clearly affected also by the clinician’s experience with the medium and the procedure itself.
Office hysteroscopy is the most accurate diagnostic tool for endometrial pathologies and a second line tool after primary diagnosis deriving from 2D or 3D transvaginal ultrasound scan. Compared to the hysteroscopy performed in the operating theater under general anesthesia or sedation, there are clear benefits for the patients, such as the avoidance of taking general anesthesia, especially for patients who are at high-risk for anesthetic complications. The reduced time of the whole procedure and also the location, especially when performed in an out-of hospital environment, are crucial for the patients in order to decide. Also, the reduced cost of around 40–60%, as long as hospital and anesthetic costs are excluded, attracts more patients and also more clinicians to propose, especially in current years of financial recession. Finally the provision of this diagnostic tool in an office-based environment gives an added value to the private practice and its services, but also assists the clinicians to provide more than one choice to their patients.
Indications for diagnostic office hysteroscopy can be categorized for premenopausal and postmenopausal women.
Abnormal uterine bleeding is an indication for office hysteroscopy, if there is clear evidence of pathology at the ultrasound scan. The authors recommend that before proposing the technique, if there are no obvious ultrasonographic findings, it is wise to exclude any other endocrine, ovarian, or cervical pathology.
In terms of infertility investigation, office hysteroscopy is very useful in the investigation of the endometrial cavity in women who underwent two complete cycles of in vitro fertilization (IVF) – two failed implantations, even if there is no ultrasonographic evidence. The same indication stands for women with recurrent miscarriages – more than three consecutive miscarriages. Small endometrial polyps, uterine septae, endometrial adhesions, and cervical adhesions are common findings, which can be revealed with hysteroscopy. This approach is, also, very useful for the evaluation of the quality of the endometrium during the luteal phase.
Women who take tamoxifen as a regime for breast cancer are in need of endometrial assessment by biopsy and thus hysteroscopy is not an absolute indication, but in cases where endometrial thickness is ≥ 8 mm it is highly recommended in order to exclude an endometrial polyp or ongoing endometrial cancer [6].
Postmenopausal women with uterine bleeding should be investigated with office hysteroscopy regardless of the ultrasonographic findings, which apart from benign pathologies can lead to the diagnosis of uterine or cervical cancer. In cases of cancer the benefit of accurate diagnosis outweighs the risk of spreading neoplastic cells into the abdominal cavity and thus dilatation and curettage is advised not to be preferred over hysteroscopy [7]. A finding of an endometrial polyp in postmenopausal women is not a rare finding.
Operative procedures performed in an office-based environment are quite limited. There is no specific guideline regarding operative procedures but usually minor procedures such as endometrial biopsies, removal of endometrial polyps, dissection of loose intrauterine adhesions, removal of intrauterine devices with a missing thread or foreign objects and also for permanent tubal sterilization with the insertion of tubal coils (Essure®) are performed in the everyday clinical practice and are well tolerated by the patients. Operative office hysteroscopy can be an extension of diagnostic office hysteroscopy, as long as there are no special setup requirements and cervical preparation is not needed.
Contraindications for both diagnostic and operative hysteroscopy are heavy uterine bleeding or menstruation, vaginal infection, active pelvic inflammatory disease, and history of adverse reactions during a previous office hysteroscopy. As mentioned earlier, suspicion of cancer is not a contraindication for performing diagnostic hysteroscopy and biopsy.
Office hysteroscopy is mainly designed for the patient’s advantage. The use of hysteroscopy in an office-based environment, especially in the “one-stop” clinic, in a hospital or in a private practice, can give fast and accurate diagnosis and treatment without waiting lists and at a substantially lower cost, as hospital and anesthetic costs are excluded. Without the use of sedation or anesthesia, patients can go back to their everyday activities just after the end of the procedure. The disadvantage of the possible discomfort during the procedure or the cramp-like lower abdominal pain after are outweighed by the benefits that the patients can have.
For the clinicians in the fields of gynecology, infertility, and gynecological oncology, office hysteroscopy is the ultimate tool for accurate diagnosis of endometrial pathologies. A future management plan can be easily scheduled after the end of the procedure, unless a further pathology report from biopsies is expected.
Regarding the diagnosis, from our experience, miniature hysteroscopes with a low width inflow channel for the distention medium provide low pressure distention of the uterine cavity and so in cases of soft tissue structures like polyps, adenomyomas, and fundal adhesions we get a first more realistic depiction of the uterine cavity.
Of course the setup in a private practice is not time-consuming, as long as the time needed for the setup arrangements before and after the procedure is many times more than the procedure itself and so it is suggested that a special separate room or appointment on a specific day should be used, if the same room is to be used after for other examination purposes. In general though, in a private gynecological practice, application of office hysteroscopy extends the list of the provisional services and gives the clinician an added value, though even in our days the technique is not very widespread.
Office hysteroscopy is the undoubtful gold-standard tool for the investigation of the uterine cavity. It is a technology-based technique that has greatly evolved during the last decade, and there is still place for further improvements. Ideas for change come from the gynecologists, through the everyday practice, and should be addressed to the manufacturing companies in the field.
For the clinicians who want to apply hysteroscopy in an office-based environment, the training is much shorter and easier if they had previous training and experience in hysteroscopy under general anesthesia. This, on the other hand may restrict many clinicians from getting involved for the first time with diagnostic office hysteroscopy, which is a simple and low-risk technique. This reluctance may also derive from up-to-date guidelines, which are unclear in specific details as the type of hysteroscope to choose, provision of local anesthesia or not.
Practically, from the patient’s point of view and against all the benefits that office hysteroscopy provides, the only fear is the experience of pain and discomfort during the procedure. On the contrary pain intensity is a subjective evidence described in relative research, thus local anesthetic should always be discussed with the patients when consenting and provided according to the possible length of the procedure.
The use of flexible hysteroscopes result in less painful diagnostic procedures compared to the rigid one, so for a clinician who will only perform diagnostic hysteroscopy in the office seems like a better choice, though taking into consideration that the learning curve is longer, compared to the rigid hysteroscope.
Clinicians in the field of gynecology who are reluctant against the technique should get more familiar with office hysteroscopy where training is available, courses or any type of medical literature. Further research will probably clarify some details and assist the clinicians to take the right decisions for providing the best possible care according to the patients’ needs. We assume that in the near future almost all diagnostic and minor operative hysteroscopic procedures will be solely performed in an office-based environment either inside a hospital or in a private practice.
It is evident that office hysteroscopy enables the clinician to perform not only diagnostic but also minor operative procedures in an office setting with less risk, low cost, and better results. The near future comprises improvements in the hysteroscopic instrumentation, new energy supplies, and new systems for controlling intrauterine pressure, which will yield further benefits for the patients and the clinicians.
Insertion of intercostal drainage (ICD) tube is a common procedure that is required to drain the abnormal intrapleural collection. As the name implies, it is insertion of a tube through the intercostal space to facilitate the drainage of abnormal collection in the pleural cavity. The procedure is also known as tube thoracostomy and thoracostomy drainage. The earliest reports of thoracic drainage dates back to 5th century BC [1, 2].
The aim of thoracostomy drainage is to:
Remove fluid and air from pleural cavity as promptly as possible.
Prevent drained air and fluid from returning to pleural cavity.
Restore negative pressure in pleural cavity to help re-expand the lung.
Although, the procedure has been in practice since long, there is still no consensus in the management of chest tubes and there remains great variability in practice. The procedure of inserting a chest tube is simple, definitive in treating a majority of thoracic pathologies and may be life-saving in certain situations. However, improperly placed chest tubes and poor post-procedural care may increase the morbidity and is associated with complications in up to 40% of patients [3, 4]. It is therefore imperative that all clinicians should be well versed with this simple yet life-saving procedure.
In this chapter, we will discuss various aspects of intercostal drainage including the prerequisites, technique of insertion, post-procedural care, complications and common pitfalls in the management of chest tubes in the light of the recent advances and updates.
An ideal thoracostomy tube should:
Allow collected air and fluid to drain out from the chest.
Contain a one-way valve to prevent air and fluid from returning back into the chest.
Allow maintenance of negative intra-pleural pressure (the normal intrapleural pressure is −3 mmHg that decreases further on inspiration).
Have provision for applying higher negative pressure to help in expanding the lung.
Allow accurate measurement of drained fluid and air.
Tube thoracostomy is required to drain any abnormal collection in the pleural cavity, that includes:
Air: Pneumothorax
Fluid: Pleural effusion
Blood: Hemothorax
Pus: Empyema
Chyle: Chylothorax
Prophylactically following cardio-thoracic surgery to drain post-operative collection of air, fluid or blood
The modern, commercially available chest tubes are soft and pliable that are either made up of Polyvinyl chloride (PVC) or silicone (Figure 1).
Intercostal drainage tube (chest tube).
The red rubber or malecot tube drains (Figure 2) are sometimes used as thoracostomy tubes mostly in resource constraint settings because of their low-cost, however their use is not advisable as they are difficult to retain, get kinked easily, wither rapidly and at times may break.
Malecot (red rubber) tube drain.
Chest tubes come in various sizes from 6 French gauge (F) to 40 F. Larger the size of the tube, greater is its diameter. One F is equal to 0.033 cm. To know the diameter of the tube from the F size, one need to multiply F size by a factor of 0.033, so a chest tube of size 24 F will have an internal diameter of approximately 0.8 cm.
Some chest tubes are available with metallic trocar that has a pointed end (Figure 3).
Chest tube with metallic trocar.
These are meant to insert in intercostal space after making a small skin incision, without dissecting the intercostal muscles. Although, this makes the procedure fast, there is a higher risk of injury to the intrathoracic organs and as such use of chest tubes with trocars should be discouraged [3, 5, 6]. Most of the chest tubes are open from one end while the other end is sealed. There are side holes or eyes on the tube and the markings are printed on it. There also is a radiopaque line all along the length of the tube that helps in identifying the position of the chest tube on X-ray (Figures 1 and 4).
Radiopaque line in the chest tube visible on x-ray (arrow).
Insertion of ICD tube is a surgical procedure and like any other surgery, a written informed consent is required prior to the procedure. Consent may not be possible in cases where the patient requires urgent tube thoracostomy as a lifesaving measure and when he/ she is unconscious, unattended or is in extremis.
Following instruments and equipment are required for inserting the chest tube. One must ensure the availability of all necessary equipment beforehand to avoid any difficulty during the procedure.
5 ml syringe with a suitable local anesthetic. Preferably 2% lidocaine with adrenaline.
Sponge holding forceps
Bowl with solution for painting
Number 11 surgical blade with handle
Sheets for draping
A pair of medium sized curved artery forceps
An appropriately sized chest tube: See the section on ‘selecting the size of chest tube.
Silk No.1 suture on cutting needle
Needle holder
A pair of tooth forceps
Prepared underwater seal bottle or bag.
Gauze pieces
Adhesive tape for dressing
The chest tubes are available in various sizes ranging from 6 F to 40 F. There is a general understanding that large-bore tubes are required to drain fluid and small-bore tubes are sufficient to drain air. There have been numerous studies on this issue, however there is no conclusive scientific data to support this idea. Large-bore tubes have been related to higher incidence of pain and patient discomfort without any significant advantage in draining the intra-pleural fluid. In various studies, small-bore tubes have been found to be equally effective to drain pleural effusion and hemothorax [7, 8, 9, 10, 11]. This has generated wider interest in use of small-bore tubes for thoracostomy. Conventionally, for most of the clinical conditions requiring tube thoracostomy a 24–32 F chest tube is inserted, depending on the expected underlying pathology, however tubes smaller than 24 F may be sufficient to drain pneumothorax.
The reservoirs for collecting the pleural drainage are available either in the form of bags or single or multiple chambered plastic bottles (Figure 5A and B).
A: Two chambered plastic bottle and B: ICD bag.
In both of these reservoirs, there are markings for calculation of effluent. In addition, there is also a marking for ‘initial fluid level’. Before connecting the reservoir to the chest tube, a sterile fluid like normal saline should be filled till this mark. As the chest tube is connected with the tube in the reservoir that remains below the ‘initial fluid level’, the air from the environment cannot gain access to the pleural cavity, however the intrapleural collection may egress easily into the reservoir, thus it functions as a one-way valve or ‘under water seal’.
Any suitable local anesthetic is appropriate for the procedure. Plain Lidocaine 2% solution and Lidocaine 2% with adrenaline are commonly used drugs for ICD insertion. A volume of nearly 5 ml is sufficient to anesthetize the local site. Local anesthesia may not be required where the patient is obtunded or unconscious and ICD insertion is required urgently.
The step by step procedure is demonstrated in the video supplemented with this article.
Inserting Intercostal drainage tube: step by step.
Although the ICD can be inserted while the patient is sitting, leaning forward with the forearms resting over a stool, the supine position is less cumbersome and more comfortable for both patient and the doctor. In addition, the patient may not be able to sit for the procedure due to the underlying clinical condition. We prefer to insert ICD tube in supine position. The patient lies on the table close to the edge with arm abducted over the head if possible.
The ideal site of inserting ICD is 4th or 5th intercostal space just anterior to the mid axillary line. One may calculate the desired intercostal space by considering sternal angle as landmark. The rib attached to the level of sternal angle is the second rib, subsequent ribs can be counted while palpating the chest wall distally and laterally. There is an alternative way of counting the ribs and the intercostal spaces which is quick and is particularly helpful in obese patients and in presence of subcutaneous emphysema. The level of the nipple in males and inframammary crease in females can be taken as a reference point- a line drawn from this point laterally to a point where it intersects the mid-axillary line is marked and the site for insertion of the chest tube is just anterior to this.
In case, the chest tube is being inserted prophylactically during thoracic surgery, the site of insertion is selected under vision in appropriate intercostal space.
A wide area around the predetermined site of ICD insertion is painted with a suitable antimicrobial solution (Chlorhexidine or Povidone-iodine) and is draped. If the patient is awake and conscious, 5 ml of local anesthetic solution (preferably 2% lidocaine with adrenaline) is infiltrated in the overlying skin, intercostal muscles and pleura at the site of ICD insertion. Before injecting the local anesthetic, one should ensure that the needle is not in a blood vessel by pulling the plunger of the syringe back. For the adequate effect of local anesthesia, it is prudent to wait for at least 2 minutes before making the incision.
An incision measuring nearly 1.5–2 cms is made by a number 11 surgical blade at the predetermined site of ICD insertion along the long axis of the rib in the intercostal space just over the upper border of the lower rib. This is done to prevent injury to the neurovascular bundle that runs along the lower border of the ribs.
Using a medium sized curved hemostatic clamp, the subcutaneous tissues and inter-costal muscles are dissected bluntly till the parietal pleura is reached. By the tip of the closed hemostatic clamp, gentle pressure is then applied till there is a feeling of ‘give way’ which marks the entry into the pleural cavity. The entry into the pleural cavity is also confirmed by the escape of intra-pleural collection like air, fluid or blood (as the case may be). One should be careful enough not to apply undue force while puncturing the pleura as this may cause injury to lungs or mediastinal structures. The jaws of the hemostatic clamp are then opened while withdrawing the instrument to increase the size of the thoracostomy wide enough to allow the entry of index finger. This should be followed by ‘finger thoracostomy’. The index finger is inserted through the thoracostomy site to explore the pleural cavity for presence of any pleuro-pulmonary adhesions. In case they are present, adhesiolysis is performed to create space inside the pleural cavity for the chest tube. This step is important as attempts to insert a chest tube without ensuring space between the lung and the chest wall may injure the lung, cause air leak from the damaged lung parenchyma and such improperly placed tube may fail to drain the intra-pleural collection.
Following finger thoracostomy and ensuring safe space inside the pleural cavity to accommodate the chest tube, an adequately sized chest tube is then taken. The tip of the tube from the open end (the end that should lie inside the thoracic cavity) is held with the tip of the hemostatic clamp and the rest of the tube is held parallel to the instrument. The tube is introduced inside the pleural cavity, the instrument is then released and the tube is inserted gradually by guiding it to lie posteriorly and superiorly by using the same instrument aided by the index finger of the opposite hand to the point till the last eye (hole) on the chest tube is at least 5 cms inside the pleural cavity (this can be confirmed by looking at the markings over the chest tube). The limit to which the ICD tube needs to be put in depends on the build of the patient. In a patient with an average built a length till 8–12 cms inside the chest is sufficient.
The tube is then clamped by using an artery forceps (hemostatic clamp) close to its distal (closed) end. The end of the chest tube is now cut and is connected with the tubing of the underwater seal using the connector provided with the chest tube. The length of the tube of under-water seal apparatus should not be unduly long as the fluid column in the tube will provide resistance to the egress of intrapleural collection compromising the drainage. A good rule is not to allow any loop in the draining tube between the connector and the tubing of the reservoir.
The chest tube is then fixed by silk suture no.1. For better fixity, it should be anchored on either side. While fixing, one must ensure to take deep bites through the soft tissues close to the tube. Fixing the tube by taking superficial bites (including skin only) may leave potential space around the tube at the site of entry in the intercostal space which may lead to subcutaneous emphysema in cases of pneumothorax and may increase morbidity. Some clinicians prefer purse string suture for fixation of the tube but that leaves an ugly scar following removal of the chest tube and as such is not necessary. A dressing is now applied at the ICD site and the tube may then firmly be reinforced at the site by using adhesive tapes. This completes the procedure.
The free drainage of the collected material from the pleural cavity and the movement of the column of the fluid in the tube confirms the adequate position of the chest tube. The chest should now be auscultated, improvement in the breath sounds suggests success of the procedure. A chest X-ray is then performed for confirmation of proper positioning of the tube radiologically.
Some authors advocate creation of an oblique passage or ‘tunnel’ in the chest wall to insert the tube, primarily to decrease the incidence of recurrent pneumothorax following removal of the chest tube [12]. In this technique incision is made one intercostal space below the pre-determined site of thoracostomy, the skin and soft tissues of the chest wall are then bluntly dissected to reach the site of thoracostomy thereby creating a curved passage through the chest wall for introduction of the chest tube. This requires additional time at the expense of no added advantage and therefore is not required.
Utmost care should be exercised while nursing a patient with chest tube. The reservoir should remain below the level of the chest at all times. Raising the reservoir above the chest level may result in passage of the fluid from the reservoir back into the pleural cavity. While turning or shifting the patient, one must ensure that the tube is not held or entangled in the patient’s bed. This may result in accidental displacement or dismantling of the tube. The outlet of the reservoir should remain open at all times especially in patients with pneumothorax or air leak. The closed outlet of the reservoir may lead to failure of decompression of pneumothorax leading to development of life-threatening tension pneumothorax. For the same reason, the tube should not be clamped at any time except while changing the fluid in the reservoir, collecting a sample of effluent or while planning to remove the chest tube. The patient should be closely monitored during this period.
The patient should be motivated for active physiotherapy and incentive spirometry (Figure 6).
Patient performing incentive spirometry.
This aids in faster resolution of pleural collection and thereby early removal of the ICD tube. In case, the patient is unable to do active physiotherapy, passive physiotherapy should be performed. All efforts must be made to ambulate the patient early. The chest tube must be secured carefully while patient mobilizes and the drainage bag (reservoir) should be kept well below the thoracostomy site.
The ICD site should be carefully examined every day for signs of local infection like peri-tubal inflammation or tenderness. The dressing needs to be changed in case it is soaked. Extreme care must be taken while dressing the ICD site lest the tube is displaced or dismantled. The patient should be clinically monitored every day and the volume of drained fluid should be charted carefully in the patient’s record. The reservoir should be emptied once it is full up to 3/4 of its capacity. A new reservoir with prepared under water seal or disposable reservoir (in case of digital chest tube drainage systems) is kept ready while changing the reservoir. In resource constraint settings the same reservoir may be reused. It is important to follow universal precautions while changing the reservoir. The chest tube is clamped and the filled reservoir is disconnected from the tube, the new reservoir is then connected or fluid is filled up to the ‘initial water level’ mark (or till the outlet tube is at least 2 cms below the water level) in case one contemplates to use the same reservoir. Once the reservoir is reattached, the tube is unclamped. It is important to prepare the equipment beforehand while changing the reservoir to keep the time of occlusion of the chest tube to minimum possible.
The practice of performing daily x-ray has been questioned by many authors and it is suggested that this may not be required if there is pleura to pleura apposition in the post-procedure x-ray and the patient is improving clinically [13].
Appropriate oral or parenteral analgesics are administered depending on the underlying condition for which tube thoracostomy was necessitated. There has been much debate on the use of antibiotics following tube thoracostomy. There is no evidence to support the routine use of prophylactic antibiotic therapy following the procedure [14, 15]. However, the antibiotics may be needed for other associated causes for which tube thoracostomy was performed like in empyema thoracis or in a patient of trauma with soft tissue injuries.
The use of controlled suction (−10 to −15 cm saline) to the outlet of the reservoir may help in faster resolution of intrapleural collection and promote early pleura to pleura approximation. This is most useful following pulmonary resections and may decrease the incidence of persistent post-operative space problems. In our practice, we apply overnight suction in patients undergoing pulmonary resection surgery (except following pneumonectomy). At times, the application of suction may result in pleural pain, the amount of suction should be decreased in such situations. In case of increased air leak on application of suction, the suction may be decreased or avoided altogether.
Blockage of thoracostomy tube is not uncommon and occur frequently in hemothorax. Careful observation of the ICD tube and the ensuring drainage of the fluid are paramount to detect this complication early. If appropriate measures are taken in time, the possibility of maintaining the tube patency are high.
Various manipulations can be performed to restore the patency of blocked ICD tube. These include tapping, milking and stripping of the tube. These measures are successful only with partial blockage of the tube and should not be performed routinely to prevent blockage. There is theoretical possibility of generation of high intrapleural pressures with stripping and milking. Some authors have raised concern that this may cause pulmonary injury, however we have not observed any clinically significant adverse effects of these procedures. The practice of flushing the blocked tube by instilling sterile solutions should be discouraged as this may increase the chances of introducing infection from outside with resultant increase in the incidence of empyema. Some clinicians have used novel methods like using a fogarty balloon catheter to unblock the chest tube [16] or use of advanced systems to either prevent clot formation inside the tube [17] or wipe the inside of tube to unblock it [18].
A loop is formed in the ICD tube and the intrapleural fluid is allowed to accumulate in this loop. The tube is then clamped proximal to this collected fluid. With all aseptic measures the external surface of the ICD tube near its connection with the tubing of the reservoir is cleaned with alcohol based antiseptic solution. The tube is then disconnected from this end and the sample is collected in a sterile container. The ICD tube is then reconnected with the reservoir tube and is unclamped.
There are no fixed or universally agreed criteria that applies to all patients for guiding removal of the thoracostomy tube. There is great heterogeneity in practice, however the rule of thumb is that the chest tube should be removed once it has served its purpose. If the patient is clinically well, there is no more air leak than on forced expiration, no expanding subcutaneous emphysema, no blood, pus or chyle in the effluent and the volume of the fluid being drained is less than 250 ml, the tube can be safely removed. In case of residual space following pulmonary resection with persistent low volume air leak (no more than on forced expiration) beyond day 5, the chest tube may be clamped for up to 24 hours and a repeat x-ray is performed. The patient should be closely monitored during this period for tachypnoea or dyspnea. In case the patient remains asymptomatic and the pneumothorax does not worsen, the chest tube may be removed. The same may be done in case of persistent non-expanding effusion. This practice however, carries the risk of serious side effects if the patient monitoring following clamping of the tube is not diligent. The use of digital chest tube drainage devices might obviate this risk. The chest tube may be safely removed if the air leak is <40 ml/ min over 24 hours [19]. Alternatively, in patients with prolonged air leak (beyond day 5), a Heimlich valve may be applied to the chest tube and the patient may be followed on outpatient basis with a plan to remove the tube later allowing more opportunity for the residual lung to expand. We have recently proposed a protocol for removal of chest tubes following thoracic surgery that have enabled us to decrease the chest tube indwelling time [20].
In some specialties like Colorectal and Gynecological Surgery, the Enhanced Recovery After Surgery (ERAS) protocol has been well established. This has recently been proposed for patients undergoing oncological major lung resection surgery too. The guidelines suggest that chest tubes may safely be removed with a non-chylous fluid output of up to 450 ml/ day in absence of air leak or minimal air leak detected by the digital chest tube drainage systems [21].
The view is equally divided regarding removal of the chest tube during end-inspiration or end-expiration [22, 23]. In a Randomized Controlled Trial by Bell RL et al., there was no significant difference between the complications following removal of the chest tube at either the height of inspiration or expiration and both methods were considered safe [23]. The incidence of recurrent pneumothorax is likely to be multifactorial and correlates poorly to the method of chest tube removal alone [23, 24]. We prefer to remove the chest tube by a swift motion followed immediately by sealing of the thoracostomy wound by appropriate dressing material irrespective of the phase of respiration.
The complications of tube thoracostomy may be divided into 3 phases:
During insertion of the tube:
Hemorrhage from the ICD site
Injury to the lung and the mediastinal structures
Misplacement of the tube
During the indwelling time of the chest tube:
Displacement or dislodgement of the tube
Subcutaneous emphysema
Kinking
Blockage
Fracture of the tube
Empyema thoracis
Wound infection
Re-expansion pulmonary edema
Following removal of the tube
Recurrent pneumothorax or pleural effusion
Thoracostomy site pain
Hemorrhage from the ICD site may be avoided by carefully siting the thoracostomy incision on the upper border of the lower rib in the desired intercostal space. This avoids the damage to the neurovascular bundle that runs along the lower border of the rib. All aseptic measures should be taken while inserting the chest tube and later while handling the tube during the post procedural care to prevent wound infection and empyema. Care should be exercised while nursing and mobilizing the patient with chest tube to prevent accidental displacement or dislodgement of the tube.
To prevent re-expansion pulmonary edema, the pleural cavity should be gradually decompressed. Sudden evacuation of more than one liter of fluid from the thoracic cavity should be avoided. It is desirable to monitor the intrapleural pressure while draining large amount of fluid from the pleural cavity. The intrapleural pressure should not be allowed to fall below −20 cm saline at any point of time.
A pitfall is different from complication and is defined as a hidden or unsuspected danger or difficulty that may lead to adverse events. The awareness of a pitfall and preparation to act swiftly in such eventuality may help in averting the complication arising from it. Following are the common pitfalls in ICD tube management:
Missed diagnosis: ICD tube placed in a patient with large diaphragmatic hernia suspecting it to be a loculated pneumothorax. A careful history and diligent look at the x-ray will avoid this pitfall (Figure 7A and B).
Placement of ICD on wrong side: One should confirm the side with pathology before putting the chest tube. The history of the patient, clinical notes and the radiological findings should be correlated to correctly identify the side of pathology.
A large thoracostomy incision may result in potential space around the chest tube. This coupled with fixation of the tube by superficial skin suturing results in development of a closed plane in the subcutaneous tissues. Peri-tubal air leak in this situation may lead to massive surgical emphysema with attended morbidity and mortality.
Avoiding digital exploration of the pleural cavity may result in injury to pulmonary parenchyma in addition to improper positioning and kinking of the tube (Figure 8).
One must perform ‘finger thoracostomy’ before inserting the chest tube to avoid this from happening.
Use of tubes with trocar and applying undue force while gaining entry to the pleural cavity may result in injury to various thoracic, mediastinal or intra-abdominal organs.
Poor placement result in a tube that may be:
Too in: may impinge on to the mediastinal structures (Figure 9A and B).
Too out: the eye (hole) of the tube may lie in the subcutaneous tissues with resultant subcutaneous emphysema (Figure 10).
Mispositioned or kinked resulting in poor drainage (Figures 11–14).
Poor fixation of the chest tube may result in accidental displacement or dislodgement (Figure 11). The chest tube should be anchored properly with number 1 silk suture. An additional suture from the opposite side improves the fixation and decreases the chances of this mishap.
Improper filling of the reservoir (under water seal) with sterile solution so that the outlet tube is not beneath the water column may result in pneumothorax.
Raising the reservoir above the level of the chest may result in drainage of the collected material back into the thoracic cavity. The reservoir should remain below the chest level of the patient at all times.
Clamping the tube while shifting or mobilizing the patient may result in tension pneumothorax. The outlet of the reservoir should be kept open at all times to prevent this.
A: Left sided diaphragmatic hernia with large gastric shadow. B: Chest tube inserted in a patient of diaphragmatic hernia misdiagnosed as hydropneumothorax.
A kinked chest tube.
A & B: Chest tube impinging on mediastinal structures.
Eye of chest tube in subcutaneous tissues with subcutaneous emphysema.
Chest tube (arrow) about to come out.
Chest tube lying outside the chest wall.
Mispositioned tube over the diaphragm (arrow).
Mispositioned tube lying in abdomen (arrow).
With the advancement in technology, newer equipment has become available that may help in decreasing some of the complications associated with the tube thoracostomy, make the assessment of drainage more objective and accurate thus helping in better management of ICD tubes. Some of the advancement in the recent times are:
Devices for better fixation of the chest tubes: Some devices are available that claim better fixation of the chest tubes [25], others have been tested on animal models and may soon become available [26].
Digital chest tube drainage systems: This has been perhaps the most significant advancement that is now the part of most modern thoracic surgery units (Figure 15).
A patient being managed on digital chest tube drainage system following thoracotomy.
The use of these drainage systems has been associated with improved decision-making regarding chest tube management, decrease complications, improved quality of life and reduce the hospital stay [27, 28, 29] These are light weight, portable system with a disposable reservoir that may be replaced once full. The main advantages of this system are:
It does not require an ‘underwater seal’ thus eliminating the risk of accidental pneumothorax and passage of drained material from the reservoir back to the chest.
It allows accurate measurement of drained fluid and air over time and thus helps in assessment of the trend of drainage (Figure 16A & B).
A & B: Objective depiction of air and fluid drainage and trend of drainage in digital chest tube drainage system.
This may help the clinician in making decision for removal of chest tube more objective and accurately.
Continuous controlled suction may be applied to the chest tube that remains constant irrespective of the position of the drainage system.
The patient may easily carry the device while ambulation without the risk of changes in pressure effecting drainage or accidental drainage of the collected material back in chest.
Chest tube systems with inbuilt mechanism to keep the inside of the tube clean to prevent clogging [16, 18].
Motion activated systems for prevention of clot formation inside the chest tube: This system uses motion-activated energy (vibration) primarily to prevent early adhesion of clots within the internal chest tube surface and thus maintains the patency of the chest tube [17].
Insertion of ICD is a common, simple yet lifesaving procedure. All clinicians should be well versed with the appropriate technique of inserting the thoracostomy tube and various aspects of its management. Although simple, it is associated with high rate of complications that primarily occur due to improper technique of insertion or poor post-procedural care. Awareness of these factors will make the procedure safer with improved outcome.
There are no conflicts of interest.
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