Chest tube placement

Last updated: December 1, 2023

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Summarytoggle arrow icon

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 reexpansion pulmonary edema.

Indicationstoggle arrow icon

Chest tube placement may be indicated if there is fluid or air in the pleural space, resulting in respiratory compromise. Specific indications include: [2][3]

Contraindicationstoggle arrow icon

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

Technical backgroundtoggle arrow icon

Thoracostomy tube

  • Definition: a clear, flexible, plastic tube used for intrathoracic drainage [3]
  • 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 [2][3][5]

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 [3]
  • 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 positioningtoggle arrow icon

Positioning [3]

  • 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 [3]

Equipment checklisttoggle arrow icon

Preparationtoggle arrow icon

Procedure/applicationtoggle arrow icon

  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. [12]
  11. Confirm tube placement and patency clinically and on CXR.
  12. Secure the tube to the chest with sutures.
  13. Apply an occlusive dressing.

Pitfalls and troubleshootingtoggle arrow icon

  • Air leaks [3][13]
  • 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

Postprocedure checklisttoggle arrow icon

  • Tube sutured securely
  • Tube attached to drainage system
  • Sharps disposed of safely
  • Chest tube placement confirmed on CXR
  • Procedure documented
  • Clinical reassessment performed

Complicationstoggle arrow icon

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

Referencestoggle arrow icon

  1. $Contributor Disclosures - Chest tube placement. All of the relevant financial relationships listed for the following individuals have been mitigated: Alexandra Willis (copyeditor, was previously employed by OPEN Health Communications). None of the other individuals in control of the content for this article reported relevant financial relationships with ineligible companies. For details, please review our full conflict of interest (COI) policy:.
  2. Walls R, Hockberger R, Gausche-Hill M, Erickson TB, Wilcox SR. Rosen's Emergency Medicine 10th edition- Concepts and Clinical Practice E-Book. Elsevier Health Sciences ; 2022
  3. Roberts JR. Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute Care. Elsevier ; 2018
  4. Shen KR, Bribriesco A, Crabtree T, et al. The American Association for Thoracic Surgery consensus guidelines for the management of empyema. J Thorac Cardiovasc Surg. 2017; 153 (6): p.e129-e146.doi: 10.1016/j.jtcvs.2017.01.030 . | Open in Read by QxMD
  5. MacDuff A, Arnold A, Harvey J. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax. 2010; 65 (Suppl 2): p.ii18-ii31.doi: 10.1136/thx.2010.136986 . | Open in Read by QxMD
  6. Kwiatt M, Tarbox A, Seamon MJ et al. Thoracostomy tubes: A comprehensive review of complications and related topics. Int J Crit Illn Inj Sci. 2014; 4 (2): p.142.doi: 10.4103/2229-5151.134182 . | Open in Read by QxMD
  7. Inaba K, Lustenberger T, Recinos G, et al. Does size matter? A prospective analysis of 28–32 versus 36–40 French chest tube size in trauma. The Journal of Trauma and Acute Care Surgery. 2012; 72 (2): p.422-427.doi: 10.1097/ta.0b013e3182452444 . | Open in Read by QxMD
  8. Sundaralingam A, Banka R, Rahman NM. Management of Pleural Infection. Pulm Ther. 2020.doi: 10.1007/s41030-020-00140-7 . | Open in Read by QxMD
  9. Mei F, Rota M, Bonifazi M, et al. Efficacy of Small versus Large-Bore Chest Drain in Pleural Infection: A Systematic Review and Meta-Analysis. Respiration. 2023: p.1-10.doi: 10.1159/000529027 . | Open in Read by QxMD
  10. Beeton G, Ngatuvai M, Breeding T, et al. Outcomes of Pigtail Catheter Placement versus Chest Tube Placement in Adult Thoracic Trauma Patients: A Systematic Review and Meta-Analysis. Am Surg. 2023; 89 (6): p.2743-2754.doi: 10.1177/00031348231157809 . | Open in Read by QxMD
  11. American College of Surgeons and the Committee on Trauma. ATLS Advanced Trauma Life Support. American College of Surgeons ; 2018
  12. Broderick SR. Hemothorax. Thorac Surg Clin. 2013; 23 (1): p.89-96.doi: 10.1016/j.thorsurg.2012.10.003 . | Open in Read by QxMD
  13. Patel NJ, Dultz L, Ladhani HA, et al. Management of simple and retained hemothorax: A practice management guideline from the Eastern Association for the Surgery of Trauma. Am J Surg. 2021; 221 (5): p.873-884.doi: 10.1016/j.amjsurg.2020.11.032 . | Open in Read by QxMD

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