Tube thoracostomy is the insertion of a tube (chest tube) into the
pleural cavity to drain
But the tube can also be used to instill medications for
Iatrogenic pneumothorax, most commonly due to central line
Bronchopleural fistula, postoperative or due to mechanical
Chest trauma (blunt or penetrating)
Postoperative following thoracic or upper abdominal
Infected effusion (i.e., empyema, Para pneumonic effusion)
Considered for those about to undergo air transport who are at risk
• Patients with penetrating chest wall injury who are intubated or
about to be intubated
• Pleurodesis – Chest tube insertion to facilitate the
instillation of sclerosing agents into the pleural space is
indicated for the treatment of refractory effusion
• The need for emergent thoracotomy is an absolute contraindication
to tube thoracostomy.
• Relative contraindications include the following:
Pulmonary, pleural, or thoracic adhesions
Loculated pleural effusion or empyema
Skin infection over the chest tube insertion site.
Blind insertion of a chest tube is dangerous in a patient
with pleural adhesions from
previous pleurodesis, or
prior pulmonary surgery;
so guidance by ultrasound or CT scan without contrast is
The proper equipment should be gathered and
The patient assessed to determine the optimal chest tube
Location of placement.
The need for prophylactic antibiotics prior to the placement
of thoracostomy tubes depends upon the clinical
Prophylactic antibiotics are not warranted for chest
tubes placed in the setting of
spontaneous pneumothorax or
other non- traumatic indications
Prophylactic antibiotics are warranted for chest tubes
placed in the setting of
Trauma, particularly in patients with
• The optimal duration of antibiotic therapy is uncertain; a
single dose may be administered, or in cases of penetrating
injury, antibiotic therapy may be continued for up to 24
• There is no evidence of benefit for continuation of
antibiotics for longer than 24 hours.
Chest tube drainage device with water seal (autotransfuser unit is an
Suction source and tubing
Lidocaine 1% with epinephrine
Syringes, 10-20 mL (2)
Needle, 25 gauge (ga), 5/8 in
Needle, 23 ga, 1.5 in; or 27 ga, 1.5 in; for
instilling local anesthesia
• Blade, No. 10, on a handle
Large and medium Kelly clamps
Large curved Mayo scissors
Large straight suture scissors
Silk or nylon suture, 0 or 1-0
Gauze squares, 4 x 4 in (10)
Sterile adhesive tape, 4 in wide
Chest tube of appropriate size
Man - 28-32F
Woman - 28F
Child - 12-28F
Infant - 12-16F
Neonate - 10-12F
• The patient should be positioned supine or at a 45° angle. (Elevating
the patient lessens the risk of diaphragm elevation and consequent
misplacement of the chest tube into the abdominal space.
• The arm on the affected side should be abducted and externally
rotated, simulating a position in which the palm of the hand is behind
the patient's head.
• A soft restraint or silk tape can be used to secure the arm in this
location. If a restraint is used, make sure that good blood flow to the
hand is present.
• A chest tube's internal diameter (d) and the viscosity (μ) of
the fluid determine volume of fluid flow.
Chest tubes are available in a range of French sizes from 14 to
A 28 Fr tube will drain about 15 L/min for air but about
thirty times less for liquids.
• Compared with a transudate or sterile exudate, the
drainage of more viscous fluids (eg, pus or blood) requires
a larger bore chest tube to obtain the same flow rate.
• Chest tubes can be straight or angled .
• Angled chest tubes are used often in the surgical setting to
assure placement in the posterior cost phrenic sulcus.
Spontaneous and iatrogenic =16-24 Fr.
In patients who develop pneumothorax during
mechanical ventilation = 28 Fr
In patients with severe underlying lung
disease who have a pneumothorax (iatrogenic or
spontaneous) = 28 Fr
For traumatic pneumothorax = 36-40 Fr
It is important to distinguish between air leaks that are
due to an alveolar-pleural fistula and those due to a bronchopleural fistula.
• TENSION PNEUMOTHORAX
If immediately available, a standard thoracostomy
tube (24 or 28 Fr, 36 Fr for trauma) should be placed.
Otherwise needle thoracostomy should be
performed, followed by chest tube placement as soon as
Closed chest trauma
Secondary to Malignancy
The goals of tube thoracostomy in acute hemothorax are
Drainage of fresh blood,
Measurement of the rate of bleeding,
Evacuation of any coexisting pneumothorax, and
Tamponade of the bleeding site by apposition of the
Large-bore tubes (36 to 40 Fr) are required to reliably achieve
A small-bore catheter (8 to 18 Fr) placed under ultrasound or CT
guidance is usually adequate to drain a malignant pleural effusion
perform pleurodesis (depending on the viscosity of the
Chronic indwelling catheters (e.g., Pleurx®) are available for
outpatient treatment of recurrent malignant effusion. These
catheters come in a kit that includes disposable suction bottles and
the appropriate tubing and connectors to access the catheter.
We prefer initial image-guided placement of a small catheter
(10 to 14 Fr), with or without intrapleural fibrinolytic agents.
However, if the fluid appears more viscous, a larger tube
(16 to 24 Fr) should be used to minimize the risk of
occlusion with fibrinous debris.
Unsuccessful drainage of an effusion using a small catheter
indicates the presence of multiple loculations or very
For empyema, a 28 Fr or larger tube will likely be needed
to manage the thicker drainage, particularly if there is
debris draining with the pus.
• Failure to achieve drainage with a single tube should
prompt thoracic surgery consultation for drainage using
video-assisted thoracoscopic surgery (VATS).
The chest tube insertion site depends upon the indication
for tube placement.
Fluid collects in the dependent portion of the
chest cavity, while
Air collects in the nondependent portion.
For evacuating pneumothorax, most clinicians insert the
chest tube via an incision at the 4th or 5th intercostal space
in the anterior axillary or midaxillary line
The second intercostal space in the midclavicular line has
been suggested as an alternative site for tubesaxillary line .
• A "safe triangle” has been described as the preferred site of
insertion. This is the triangle bordered by the anterior border of the
latissimus dorsi, the lateral border of the pectoralis major muscle, a
line superior to the horizontal level of the nipple, and an apex below
Level of suction
• The typical level of suction used in the clinical
setting is -20 cm of water.
• Two techniques are most commonly used to place a chest
1-The standard technique
2-The Seldinger technique
Role of ultrasound or other imaging — Ultrasound or
other imaging modalities (e.g., fluoroscopy, computed
tomography) can be used to guide chest tube placement.
① Obtain informed consent from the patient or patient’s
② Assemble the drainage system and connect it to the suction
source. The appearance of bubbles in the water chamber is a sign
that the chest tube drainage device is functioning properly.
③ Place the patient in the supine position with the ipsilateral
arm abducted and the elbow flexed to position the hand
comfortably over the patient’s head.
Identify the fifth intercostal and the midaxillary line.
The skin incision is made in between the midaxillary and
anterior axillary lines over a rib that is below the intercostal level
selected for chest tube insertion.
A surgical marker can be used to better delineate the anatomy.
⑤ Prepare the skin around the area of insertion, preferably
with chlorhexidine or alternatively with 10 percent
Wear sterile gloves, gown, hair cover, and goggles or face shield,
and apply sterile drapes to the area
⑥ Administer analgesia
Using 1% lidocaine, anesthetize a 2 to 3 cm area of
skin and subcutaneous tissue one intercostal space below the
intercostal space that will be used to place the tube
Use the 25-ga needle to inject 5 mL of the local anesthetic
solution into the skin overlying the initial skin incision
Use the longer needle (23 or, preferably, 27 ga) to infiltrate
about 5 mL of the anesthetic solution to a wide area of subcutaneous
tissue superior to the expected initial incision.
inject approximately 10 mL of the anesthetic solution into the
• Use the No. 11 or 10 blade to make a skin incision approximately 4
cm long overlying the rib that is below the desired intercostal level of
entry. The skin incision should be in the same direction as the rib
• Use a hemostat or a medium Kelly clamp to bluntly dissect a tract in
the subcutaneous tissue by intermittently advancing the closed
instrument and opening it
• Palpate the tract with a finger as shown, and make sure that the
tract ends at the upper border of the rib above the skin incision.
Adding more local anesthetic to the intercostal muscles and pleura at
this time is recommended. Use a closed large Kelly clamp to pass
through the intercostal muscles and parietal pleura and enter into the
This maneuver requires some force and twisting motion of the tip of the
closed Kelly clamp.
This motion should be done in a controlled manner so the instrument
does not enter too far into the chest, which could injure the lung or
Upon entry into the pleural space, a rush of air or fluid should occur.
• The Kelly clamp should be opened (while still inside the pleural
space) and then withdrawn so that its jaws enlarge the dissected
tract through all layers of the chest wall as shown. This facilitates
passage of the chest tube when it is inserted.
Use a sterile, gloved finger to appreciate the size of the tract and to feel
for lung tissue and possible adhesions, as shown in the image below.
Rotate the finger 360o to appreciate the presence of dense adhesions
that cannot be broken and require placement of the chest tube in a
different site, preferably under fluoroscopy (ie, by interventional
Measure the length between the skin incision and the apex of the lung
to estimate how far the chest tube should be inserted.
If desired, place a clamp over the tube to mark the estimated
Some prefer to clamp the tube at a distal point, memorizing the
Grasp the proximal (fenestrated) end of the chest tube with the large
Kelly clamp and introduce it through the tract and into the thoracic
cavity as shown.
• Release the Kelly clamp and continue to advance the chest tube
posteriorly and superiorly. Make sure that all of the fenestrated holes
in the chest tube are inside the thoracic cavity.
Connect the chest tube to the drainage device as shown (some
prefer to cut the distal end of the chest tube to facilitate its
connection to the drainage device tubing). Release the cross clamp
that is on the chest tube only after the chest tube is connected to the
• Before securing the tube with stitches, look for a respiration-related
swing in the fluid level of the water seal device to confirm correct
intra thoracic placement. Secure the chest tube to the skin using 0
or 1-0 silk or nylon stitches, as depicted below.
• Securing sutures: Two separate through-and-through, simple,
interrupted stitches on each side of the chest tube are
recommended. This technique ensures tight closure of the skin
incision and prevents routine patient movements from dislodging the
• Each stitch should be tightly tied to the skin, then wrapped tightly
around the chest tube several times to cause slight indentation, and
then tied again.
• Sealing suture: A central vertical mattress stitch with ends left long
and knotted together can be placed to allow for sealing of the tract
once the chest tube is removed.
• Place petrolatum (eg, Vaseline) gauze over the skin incision as
• Create an occlusive dressing to place over the chest tube by turning
regular gauze squares (4 x 4 in) into Y- shaped fenestrated gauze
squares and using 4-in adhesive tape to secure them to the chest
wall, as shown below. Make sure to provide enough padding
between the chest tube and the chest wall.
Strap the emerging chest tube on to the lower trunk with a "mesentry"
fold of adhesive tape, as this avoids kinking of the tube as it passes
through the chest wall. It also helps reduce wound site pain and
discomfort for the patient. All connections are then taped in their long
axis to avoid disconnections.
Obtain a chest radiograph, like the one below, to ensure correct
placement of the chest tube.
• large bore angiocatheter can be used in hemodynamically
unstable patients for whom a suspicion of tension
pneumothorax is high.
• A 14 to 16 gauge intravenous needle/catheter attached to a
5 or 10 mL syringe is inserted along the superior margin of
the second or third rib in the midclavicular line
Managing initial drainage
• The amount of thoracostomy drainage should be assessed
on a regular basis, hourly in the setting of trauma.
Generally, an immediate drainage of 20 mL/kg or the
accumulation of >3 mL/kg per hour of blood is an indication
for thoracotomy to identify and manage thoracic vascular
• The rapid removal of large volumes of fluid from the pleural
space can be associated with re- expansion pulmonary
• So To minimize the likelihood of developing re-expansion
pulmonary edema, if the patient develops coughing, chest
pain, shortness of breath, or oxygen desaturation after
chest tube placement, the chest tube should be clamped
and no additional fluid should be removed.
• We limit initial fluid drainage to 1 to 1.5 liters by clamping
the chest tube and waiting two to four hours before
draining additional fluid, provided symptoms have resolved.
Patients with large effusions and mediastinal shift
contralateral to the chest tube may tolerate a larger
amount of initial fluid removal . Patients without
mediastinal shift or with mediastinal shift ipsilateral to the
chest tube may have a marked decrease in pleural pressure
with a small amount of fluid removal and an increased risk
of reexpansion pulmonary edema.
• Criteria: Pneumothorax
The lung is fully expanded
No visible air leak is present and air does not accumulate
when suction is removed. If there is any question as to
whether an air leak has resolved, a ―clamp trial‖ can be
performed. The chest tube is clamped and a chest radiograph
repeated at intervals (eg, 2 hours, 6 hours, 12 hours). If air
does not re-accumulate, the tube can be removed.
• Opinion is divided as to whether a chest tube placed for
pneumothorax in a patient receiving mechanical ventilation
should remain in place as long as the patient requires
mechanical ventilation even when no air leak is present.
• Criteria: Effusion
The lung is fully expanded
Daily fluid output is less than about 100 to 300 mL/day.
The threshold is individualized depending upon the indication
for the insertion and patient factors (eg, body mass)
• In preparation for removal
obtain a petroleum gauze dressing and
cut the sutures anchoring the chest tube to
If the sutures holding the skin together have
loosened, tighten them prior to chest tube removal
Have several strips of occlusive tape already
dispensed to apply to the dressing once the tube has been
Prior to removing the tube, it should be explained to
patients that they will need to inspire deeply and hold their
breath during tube removal
• Holding the dressing near the chest tube insertion site with
the nondominant hand, ask the patient to inspire and hold
his or her breath, then remove the tube quickly with the
dominant hand while simultaneously covering the insertion
site with the gauze dressing.
• Tape the dressing into place, and obtain a chest radiograph
immediately following chest tube removal, and 24 hours
later to evaluate for recurrence of pneumothorax and/or
reaccumulation of fluid.
Horizontal (over the diaphragm) - Acceptable for
hemothorax; should be repositioned for pneumothorax
Subcutaneous - Must be repositioned
Placed too far into the chest (against the apical pleura) Should be retracted
Placed into the abdominal space - Should be remove
Local - Usually responds to direct pressure
Hemothorax (lung vs intercostal artery injury) - Might require
thoracotomy if it does not resolve spontaneously
Hemoperitoneum (liver or spleen injury) - Requires emergent
Organ penetration (usually requires surgical repair)
Stomach, colon, or diaphragm - Occurs as a result of
unrecognized diaphragmatic hernia
Lung - Occurs as a result of pleural adhesions or use of a
thoracostomy tube trocar
Liver or spleen
Empyema - Chest tube (foreign object) could introduce bacteria into
the pleural space
Retained pneumothorax or hemothorax - Might require insertion of
a second chest tube
FOLLOW UP AFTER PROCEDURE
The emergency medicine
physician needs a combination of
skills tempered with patience and
the ability to keep a cool head under