CME information and disclosures
To see contributor disclosures related to this article, hover over this reference: 
Physicians may earn CME/MOC credit by reading information in this article to address a clinical question, and then completing a brief evaluation, in which they will identify their question and report the impact of any information learned on their clinical practice.
AMBOSS designates this Internet point-of-care activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only credit commensurate with the extent of their participation in the activity.
For answers to questions about AMBOSS CME, including how to redeem CME/MOC credit, see "Tips and Links" at the bottom of this article.
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 4th–5th 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 .
- Definition: a clear, flexible, plastic tube used for intrathoracic drainage 
- 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 
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 
Components: traditionally comprised 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
Landmarks and positioning
- 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.
- Safe triangle
- Standard insertion site
- Position the patient, identify the , and mark the insertion site.
- Place the patient on continuous cardiac and pulse oximetry monitoring.
- Consider if the patient is hemodynamically stable.
- and place sterile drapes.
- Administer along the anticipated tract.
- Make a 3–5 cm transverse incision through the skin and subcutaneous tissue.
- pleura at the superior edge of the rib using a Kelly clamp or blunt-edged scissors. down to the
- Apply firm pressure with the tip of the clamp to penetrate the pleura.
- Open the tip of the clamp to widen the pleural opening.
- Slide a finger into the pleural space and remove the Kelly clamp.
- Clamp the distal end of the tube.
- Guide the tube along the finger into the pleural space.
- Ensure all side holes of the tube are within the pleural space.
- Connect the tube to the chest drainage system before releasing the clamp. 
- Confirm tube placement and patency clinically and on CXR.
- Secure the tube to the chest with sutures.
- Apply an .
Pitfalls and troubleshooting
- Air leaks 
- 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.
- Do not reinsert the dislodged tube.
- Apply occlusive dressing to the tube insertion site.
- Monitor for .
- Insert a new tube through a different site if clinically indicated.
- Organ injury (e.g., heart, lung, spleen, diaphragm, colon)
- Intercostal vessel injury
- Bronchopleural fistula
- Horner syndrome
- Subcutaneous emphysema
- 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.