LAUSR

We read with great interest the article by Keeffe et al. about tube thoracostomy siting using surface anatomy and congratulate the authors for an excellent manuscript. It is an interesting topic due to the highlighted high complication rates and the associated morbidity, particularly from insertional complications, so efforts to ensure an adequate site for insertion should be pursued. For decades, physicians have been taught to perform tube thoracostomies based on anatomical landmarks, and current guidelines propose drain insertion in the triangle of safety, which is again defined by anatomical landmarks, but the safety of this has been challenged. Correct identification of the most adequate intercostal space for the procedure is also cumbersome, as women, the obese, and patients with ventilatory pathologies, such as diaphragmatic paralysis or basal consolidations, may display a higher risk of insertional complications during tube thoracostomies. We acknowledge that most trauma patients will not display ventilatory pathologies as they are often young and healthy, but when analyzing the results and limitations of the study by Keeffe et al., more than 70% of the subjects were male and there is no mention of body mass index – features which may influence the safety of the intercostal space choice. We thus share our concern of using the hair follicle as a sole indicator for a safe drain insertion. Point-of-care ultrasound (POCUS) may lessen the impact of anatomical and pathological differences among patients in terms of procedural guidance, and can be used as an adjunct for tube thoracostomies, providing adequate visualization of the diaphragm, to avoid low insertions. Studies demonstrate the potential benefits of ultrasound procedural guidance by identifying underlying structures and the most adequate intercostal space for the procedure, when compared to anatomical landmarks. Our group published a step-by-step ultrasound-guided tube thoracostomy technique that uses the identification of the safest intercostal space as the first step. Although no prospective studies have evaluated POCUS to guide chest tube insertion, we believe that it can play a major role in reducing complications especially in patients where anatomical landmarks may not be reliable (i.e. women, obese, ventilatory pathologies). POCUS is a portable, easy-to-use, and low-cost tool that surgeons should be able to easily master and the technique to evaluate the safest intercostal space for drainage can be performed in seconds, making it a good option even in emergency procedures. Routine use of POCUS as an adjunct for tube thoracostomies may provide better results in terms of complications. Therefore, we believe that the quest for the optimal technique to guide the insertion of chest drains might be coming to an end.