Protective measures undertaken during chest tube thoracostomy in COVID-19 outbreak

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a newly emerging infectious disease that was first reported in China and has become a worldwide pandemic. Many surgical procedures are continuing to be performed during this state of pandemic as is thoracic surgery. We present six cases of tube thoracostomy in COVID-19 patients and the modifications to the routine surgical technique. METHODS: We serially attached two closed underwater drainage systems (CUDS) together and added a high-efficiency particulate air (HEPA) filter to the port of the second CUDS, because the intrapleural air, which passes through the CUDS into the air in intensive care unit (ICU), may contain high concentrations of 2019 novel coronavirus (2019-nCoV). Second, we attached the chest drain to the first CUDS in order to prevent the spread of virus during the placement of drain into the pleural cavity. Third, just before opening the parietal pleura, ventilation was put on standby mode and the endotracheal tube was clamped to prevent viral dissemination to the environment. Fourth, we covered the incision with a gauze sponge soaked with sterile saline solution during pleural entry, to prevent viral dissemination into the environment. RESULTS: There were a total of six patients enrolled in our study. All these patients were diagnosed with COVID-19. The surgical indication for the chest tube thoracostomy was tension pneumothorax in all six patents. All patients had lung expansion defects and subcutaneous emphysema after intervention. Unfortunately, all of them succumbed to COVID-19, despite best available treatment. There was no COVID-19 infection reported in the healthcare professionals during this study. CONCLUSIONS: Thoracic surgical procedures may cause dissemination of high amounts of 2019-nCoV in the environment and thus are perhaps the most dangerous surgeries to perform. Variations in the thoracic surgical techniques are necessary in order to protect the healthcare providers from COVID-19.