Pediatric Chest Tube Malfunction / Malposition / Misposition / Misplacement

Etiology: Placed in patients who require drainage of air or fluid in the pleural space
Imaging: Chest tube tip should be within the pleural space
DDX:
Complications:
— Initial malposition of chest tube tip into subcutaneous tissues or lung
— Migration of chest tube tip out of pleural space
— Fracture of the chest tube during removal
— Bronchopleural fistula
Treatment: Repositioning of the chest tube tip into the pleural space or placement of a new chest tube into the pleural space
Clinical: Presents with non-reduction in the size of a pneumothorax or pleural effusion after chest tube placement or reaccumulation of pleural air or pleural fluid after successful placement of a chest tube

Radiology Cases of Chest Tube Malfunction / Malposition / Misposition / Misplacement

Radiology Cases of Chest Tube in the Subcutaneous Tissues

CXR of chest tube malfunction with chest tube in the subcutaneous tissues of the chest wall — CXR AP shows diffuse ground glass opacity throughout the lungs and a large amount of air in the right pleural space causing mediastinal shift to the left while the right-sided chest tube courses through the subcutaneous tissues of the right chest wall and never enters the right pleural space.

CXR of chest tube tip in the subcutaneous tissues of the chest wall — CXR AP shows a right sided chest tube whose tip is in the right subcutaneous tissues and not in the right hemithorax. There is a small right pneumothorax. The remainder of the tubes and lines are in appropriate position.

CXR of chest tube malfunction with chest tube migration out of the pleural space — CXR AP (above) shows left and right chest tubes within their respective pleural spaces. CXR AP (below) shows interval migration of the right chest tube out of the right pleural space into the subcutaneous tissues of the right chest wall.

CXR of chest tube in the subcutaneous tissues. — CXR AP shows body wall thickening. The tip of the left chest tube is in the left pleural space and there is a small left pleural effusion. The tip of the right chest tube is in the right subcutaneous tissues. There is a small right pleural effusion

Radiology Cases of Chest Tube Fracture During Chest Tube Removal

CXR of chest tube fracture during chest tube removal — CXR AP (left) shows a chest tube in the left hemithorax. CXR AP after chest tube removal (right) shows a long fragment of the chest tube remaining in the left hemithorax.

Radiology Cases of Chest Tube in the Lung

CT of chest tube malposition with chest tube in the lung parenchyma — Axial and coronal and sagittal CT with contrast of the chest shows a large amount of air in the left pleural space. The left chest tube is clearly located within the air space disease in the posterior left lung parenchyma in all three planes.

Radiology Cases of Chest Tube Causing Bronchopleural Fistula

CXR of bronchopleural fistula — CXR AP shows a large right pleural effusion with an air-fluid level within it – a hydropneumothorax – that is being drained by a chest tube.

CXR and CT of bronchopleural fistula — CXR AP (above) shows diffuse bilateral airspace disease and a right sided pneumothorax that is almost completely drained by a right chest tube. Axial CT with contrast of the chest (below left) shows air and fluid and a chest tube in the right pleural space and an enhancing rim sign of the pleura. There is also a bronchopleural fistula from the superior segment of the right lower lobe to the necrotic lung and pleural space (below right).

Radiology Cases of Chest Tube Puncturing An Intercostal Vessel Causing Active Bleeding

CT of chest tube puncturing an intercostal blood vessel causing active bleeding — Arterial (above) and venous (below) phase axial CT with contrast of the chest shows a large hematoma inside the ribs at the chest tube insertion site. There is also a blush of contrast near the chest tube that increases on delayed imaging representing active bleeding.

Radiology Cases of Post Operative Diaphragmatic Hernia Repair That Does Not Require a Chest Tube

CXR after congenital diaphragmatic hernia repair showing no need for a chest tube — CXR AP (above) taken immediately postop shows that the hypoplastic left lung cannot expand to completely fill the pleural space particularly in the basilar region and subsequently there is a moderate amount of air in the pleural space. This should not be called a pneumothorax. CXR AP taken 1 day later (below) shows the left pleural space now filling with fluid.

Gross Pathology Cases of Chest Tube Malfunction / Malposition / Misposition / Misplacement

CXR of chest tube malposition with chest tube in the lung parenchyma — CXR AP (left) shows chronic interstitial fibrosis and scarring in the lungs, a left-sided chest tube, and a moderately-sized basilar left pleural air collection manifesting as a deep sulcus sign. Gross pathological specimen (right) shows the left chest tube entering the upper lobe of the left lung.