ECMO-/ECLS

the 4th rib. After the administration of local anesthesia, a small transverse
incision is then made below the 4th or 5th intercostal space, anterior to the mid-
axillary line. Sharp dissection is carried through the subcutaneous tissues
above the rib into the pleural cavity. A rush of air or bloody drainage may be
noted upon entry into the intrathoracic space. A chest tube is then inserted into
the pleural space directed cephalad towards the thoracic apex for a
pneumothorax, or caudad and posteriorly for a hemothorax to optimize
drainage. The chest tube is connected to a drainage device and evaluated for
initial output. Non-absorbable suture is used to secure the tube in place and an
occlusive dressing is applied. A chest x-ray is obtained to verify tube position
and evacuation of the pneumothorax or hemothorax.
In cases of small or occult pneumothoraces, supportive care with
oxygen supplementation and close monitoring with serial chest x-rays may be
pursued. However, in children who require mechanical ventilation, tube
thoracostomy is recommended because positive pressure ventilation can
convert a simple pneumothorax into a tension pneumothorax.
Tension pneumothorax occurs with progressive accumulation of air in
the pleural space, resulting in severe ipsilateral lung compression and
mediastinal shift to the contralateral hemithorax. This is an acute life-
threatening condition and mandates immediate intervention. Diagnosis is
established clinically by diminished breath sounds on the affected side, tracheal
deviation to the contralateral side, jugular venous distention, and hypotension.
Management should not be delayed for radiographic confirmation, and prompt