CT Evaluation of intraparenchymal chest tube placement and other malpositions: A pictorial review

Tube thoracostomy is a ubiquitous procedure in trauma and critical care, yet malposition rates reach 30% in emergent settings. Intraparenchymal placement-where the tube traverses lung tissue-is a severe complication that can result in life-threatening hemorrhage, bronchopleural fistula, or lung abscess. Clinical recognition is notoriously difficult; bedside chest radiography (CXR) frequently fails to define the tube's depth relative to three-dimensional thoracic anatomy, creating a dangerous diagnostic gap. Computed tomography (CT) is the gold standard for evaluation. We review the spectrum of CT findings associated with chest tube malposition, emphasizing direct visualization of the trans-parenchymal course and critical indirect signs such as the "peritubular hematoma" (halo sign) and the "parenchymal tract" sign. Furthermore, we illustrate the radiological distinctions between intraparenchymal placement and common mimics, including intrafissural and extrapleural positions. By identifying these characteristic imaging patterns, clinicians can transition from "blind" management to definitive, evidence-based care. We propose a management algorithm based on CT findings-ranging from watchful waiting to the "do not pull" scenario for vascular injury-to guide clinical decision-making and improve patient safety in acute and critical care settings.