Chest tube placement

Chest tube placement or tube thoracostomy is a procedure in which a flexible tube is inserted between the ribs into the thoracic cavity to drain intrathoracic air, blood, or other fluid (e.g., pleural effusion, empyema), allowing for lung reexpansion. Relative contraindications include coagulopathy and multiple pleural adhesions. Chest tubes are most commonly placed at the 4^th–5^th intercostal space, between the anterior axillary and midaxillary lines. They should be inserted directly above the superior edge of the rib to avoid injuring the intercostal neurovascular bundle. A finger should be inserted into the chest tube tract to maintain patency prior to and during chest tube placement. Complications include intercostal vessel injury and reexpansion pulmonary edema.

Chest tube placement may be indicated if there is fluid or air in the pleural space, resulting in respiratory compromise. Specific indications include: ^[1][2]

• Pneumothorax
• Hemothorax
• Pleural effusion ^[3]
• Pleural empyema
• Chylothorax

• Absolute contraindications: none
• Relative contraindications
  • Coagulopathy
  • Multiple pleural adhesions
  • Pulmonary blebs

We list the most important contraindications. The selection is not exhaustive.

Thoracostomy tube

• Definition: a clear, flexible, plastic tube used for intrathoracic drainage ^[2]
• Features
  • Fenestrated end to aid drainage
  • Open end to connect to the drainage system
  • Radiopaque line with a gap at the first drainage hole to confirm placement
  • Gradation marks along the tube indicate the distance from the first drainage hole.
• Adult tube sizes by indication ^[1][2][4]
  • Spontaneous pneumothorax, empyema: small-bore tubes (e.g., 14 Fr) ^[3][5][6]
  • Traumatic pneumo- or hemothorax: large-bore tubes (e.g., 28–32 Fr) ^[7][8]

Chest drainage system

• Definition: a system that connects to a chest tube to drain the pleural space or mediastinum, acting as a one-way valve ^[2]
• Components: Traditionally compromised of three chambers
  • First chamber: collects drained fluid
  • Second chamber: functions as a water seal
  • Third chamber: controls optional suction
• Positioning: below the level of the chest to prevent backflow from the collection chamber

Positioning ^[2]

• The patient is supine with the head of the bed between 30 and 60 degrees.
• The ipsilateral arm is abducted and secured above the patient's head.

Landmarks ^[2]

• Safe triangle
  • An area of the chest that allows for thoracostomy with reduced risk of injury to vessels, nerves, and muscle
  • Extends from the base of the axilla to the 5^th intercostal space
  • Bounded by the lateral borders of the latissimus dorsi and pectoralis major
• Standard insertion site
  • 4^th or 5^th intercostal space: approximately at the level of the nipple for men and above the inframammary fold for women
  • Between the anterior and midaxillary lines

• Sterile gown and gloves
• Surgical mask
• Sterile drapes
• Antiseptic solution
• Local anesthetic (e.g., 1% lidocaine)
• Scalpel with a No. 10 blade
• Large curved Kelly clamps
• Chest tube
• Chest drainage system
• Needle driver
• Nonabsorbable suture, size 0 or 1
• Occlusive dressing

• Position the patient, identify the safe triangle, and mark the insertion site.
• Place the patient on continuous cardiac and pulse oximetry monitoring.
• Consider procedural sedation if the patient is hemodynamically stable.
• Prep the skin and place sterile drapes.

1. Administer local anesthesia along the anticipated tract.
2. Make a 3–5 cm transverse incision through the skin and subcutaneous tissue.
3. Bluntly dissect down to the pleura at the superior edge of the rib using a Kelly clamp or blunt-edged scissors.
4. Apply firm pressure with the tip of the clamp to penetrate the pleura.
5. Open the tip of the clamp to widen the pleural opening.
6. Slide a finger into the pleural space and remove the Kelly clamp.
7. Clamp the distal end of the tube.
8. Guide the tube along the finger into the pleural space.
9. Ensure all side holes of the tube are within the pleural space.
10. Connect the tube to the chest drainage system before releasing the clamp. ^[9]
11. Confirm tube placement and patency clinically and on CXR.
12. Secure the tube to the chest with sutures.
13. Apply an occlusive dressing.

• Air leaks ^[2][10]
  • Ensure all side holes of the tube are within the pleural space.
  • Ensure the occlusive dressing has a tight seal.
  • Check the tubing and chest drainage system for loose connections or damage.
  • Consult thoracic surgery if an air leak persists for ≥ 72 hours.
• Obstructed drainage: Check the tubing for kinks, clots, or fluid in a dependent loop.
• Subcutaneous tube placement: Remove the tube and sterilely insert a new tube at a different site.
• Tube dislodgement
  • Do not reinsert the dislodged tube.
  • Apply occlusive dressing to the tube insertion site.
  • Monitor for signs of respiratory distress.
  • Insert a new tube through a different site if clinically indicated.

• Tube sutured securely
• Tube attached to drainage system
• Sharps disposed of safely
• Chest tube placement confirmed on CXR
  • All gaps in radiopaque line within pleural cavity
  • No kinks along the length of the tube
• Procedure documented
• Clinical reassessment performed

• Organ injury (e.g., heart, lung, spleen, diaphragm, colon)
• Intercostal vessel injury
• Bronchopleural fistula
• Horner syndrome
• Subcutaneous emphysema
• Reexpansion pulmonary edema
• Treatment failure (e.g., persistent pneumothorax, retained hemothorax)
• Infection (e.g., peri-incisional, empyema, pneumonia)

We list the most important complications. The selection is not exhaustive.