Closed-tube thoracostomy placement is useful for a large, symptomatic, or expanding pneumothorax. Radiologists may be required to place a chest tube for treatment of a pneumothorax induced by percutaneous needle biopsy. Small bore drainage tubes are also placed using image guidance for loculated pneumothoraces in patients who have undergone lung volume reduction surgery or lung transplantation or in patients receiving ventilation for the adult respiratory distress syndrome.

The technique for CT-fluoroscopic-guided pneumothorax drainage is similar to that for drainage of pleural fluid collections. Smaller caliber chest tubes (8-10 French) are usually effective but a 12-14 French tube may be required for large pleural tears. Placement of pneumothorax tubes varies based on pneumothorax location and the patient's functional status. Computed tomography fluoroscopy is particularly useful to guide catheter placement in complex, loculated pneumothoraces (Figs. 9 and 10) [15].

In our study of 20 patients who had a variety of pleural and mediastinal collections, we found CT fluoroscopic assistance to be quite valuable, particularly in patients who were not compliant with breathing instructions and those with small or loculated collections [15]. The average procedure time in our case series was 32 min and the average CT fluoroscopic time was 143 sec.

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