Intrapulmonary malposition of a chest drain.

Sir,

Chest drain placement is a standard procedure for treating pneumothorax and pleural effusions and has a low complication rate. It is a safe and efficient procedure, if image guidance is used. If the anatomic orientation is hampered and neither air nor fluids can be initially aspirated, a more complex imaging than chest radiograph is indicated, to avoid major complications.

In case of lasting clinical problems and questionable function of the chest tube, chest radiography should be supplemented by a computed tomography (CT) scan of the thorax, in order to estimate the position of the chest tube.[1] Furthermore, the placement of the chest tube intrapulmonary or in the major fissure can sometimes be suspected on anteroposterior portable chest radiography because of the characteristics of the course's tube. In such cases a lateral radiograph would be obtained for confirmation of tube localization.[2]

We report the case of a 41-year-old male patient, who was admitted with thoracic trauma, with right pneumothorax, placing a chest tube that stayed intraparenchymal, unnoticed in the control chest radiography [Figure 1a]. This complication was diagnosed on a computed tomography scan, which was performed subsequently and was observed in the coronal, sagittal, and lateral views [Figures 1b–d].

Figure 1

Image of the chest radiograph (a) and the computed tomography scan in the coronal, sagittal, and lateral views (b-d)

Pneumothorax is present in about 20% of blunt major trauma cases, and the insertion of an intercostal tube for drainage is an effective form of treatment.[3] However, the procedure might have to be repeated due to ineffective drainage in patients with tube malposition, in whom the drain is not directed to the apex or is located intraparenchymal or in the fissure.

The placement of a chest tube in the lung parenchyma is a rare complication that occurs more frequently in the presence of pleural adhesions or previous lung disease.[4] It may not lead to any clinical problem, but may cause a bronchopleural fistula, which can be massive and even fatal if it affects the pulmonary vessels. A chest radiograph taken after insertion of the tube does not show its exact location; computed tomography is the imaging technique that would give us the diagnosis of this complication.[5]