This document provides information about chest tube insertion and care. It describes the indications for chest tubes including pneumothorax, hemothorax, and fluid drainage. It outlines the equipment, anatomy, procedure steps, post-procedure care, and potential complications of chest tube placement. The timing of chest tube removal depends on indication and imaging showing full lung re-expansion and cessation of fluid or air leaks.

1. CHEST TUBE

2. Objectives
• Describe indications and contraindications for
chest tube placement.
• Describe equipment necessary for procedure.
• Describe pre- procedure steps.
• Describe steps of the procedure.
• Describe post- procedure steps.
• Describe possible complications of procedure.

3. Indications
Emergency
• Pneumothorax
• Traumatic
hemopneumothorax
• Esophageal rupture
Nonemergency
• Pleural effusion
• Empyema or
parapneumonic
effusion
• Cyclothorax
• Post pneumonectomy
bronchopleural fistula

4. Contraindications
• Infection over insertion site
• Uncontrolled bleeding diathesis/coagulopathy
• Pulmonary bullae
• Loculated pleural effusion or empyema
• Pulmonary, pleura or thoracic adhesions

5. Pre- drainage risk assessment
• Risk of hemorrhage :
– Any coagulopathy or platelet defect should be corrected prior to
chest drain insertion.
• Following differential diagnosis requires careful radiologic
assessment :
– Pneumothorax & bullous disease.
– Lung collapse & pleural effusion.
• Contraindication to chest drain insertion :
– Lung densely adherent to the chest wall throughout the
hemithorax.
– The drainage of a post pneumonectomy space should only be
carried out by or other consultation with a cardiothoracic
surgeon.

6. Chest tube
• 20 inches long, 4-6 eyelets, radio-
opaque line, range in size (gauge)
8 French up to 40 French.
• Chest tube types :
– Thoracotomy chest tube (Straight,
right angled/ silicon, PVC)
– Trocar chest tube (2- 3 eyelets)
– Malecot catheter
• Selection of chest tube depend
on :
– Size/ age of patient
– Type of drainage (air/ fluid)
– Duration of drainage

7. Anatomy of chest tubes
Tip with drainage holes
and “sentinel eye”
Body, with distance
markings.
Tail, with taper.

8. According to patient age According to disease condition
Infants and young children (8F- 12F) Pneumothorax (8F- 14F)
Children and young adults (16F- 20F) Malignant effusion (10F- 14F)
Pleurodoesis
Most adults (24F- 32F) Expyemas (24F- 28F)
Large adult (36F- 40F) Hemothorax (28F- 32F)

9. Materials
• Iodine & alcohol swabs for skin prep
• Sterile drapes & gloves
• Scalpel blade & handle
• Clamp
• Silk suture
• Needle holder
• Petrolatum-impregnated gauze
• Sterile gauze
• Tape
• Suction apparatus (Pleuravac)/underwater seal apparatus
• Chest tube (size 32 to 40 Fr, depending on clinical setting)
• 1% lignocaine with epinephrine, 10 cc syringe, 25- & 22-g needles

11. Anatomy of drainage canister
• Typically used to collect
chest tube contents (air,
blood or effusions)
• Have 3 chambers :
– The drainage collection
chamber
– The water seal chamber
– The suction control
• Needs to stay below the
level of the patient’s
chest.

12. Drainage canister
One bottle system
• Simplest set up
• First tube submerged in 2cm
water creates a water seal.
• Second tube connected to wall
suction.
• Excessive accumulation of fluid
can cause decreased function of
the unit.
Two bottle system
• Separate bottle for collecting
drainage and for water seal.
• Air from the pleural space travels
through the collecting bottle to the
water seal bottle and exists into the
atmosphere.
• Separate bottle for drainage means
more fluid can be collected before a
new bottle is needed.

13. Three bottle system
• Separate bottle :
– For collecting drainage
– For water seal
– For suction control
• Level of fluid in the suction
control bottle determines the
amount of suction provided.
• Rarely used due to bulkiness.
Plastic multi- chamber
system
• Commercially available
• Incorporated into three
bottle system into one
unit.

14. Heimlich valve
• Mechanical one way valve.
• Allow air to escape from chest.
• Prevent air from entering
chest.
• Advantages :
– Doesn’t require water to
operate.
– Not position sensitive.
– Early ambutation of patient.
• Disadvantages :
– Less patient assessment
information.
– Cant see changes in intra-
pleural space.

15. Pre- procedure patient education
• Obtain informed consent
• Inform the patient of the possibility of major
complications and their treatment
• Explain the major steps of the procedure, and
necessity for repeated chest radiographs

16. Pre- treatment evaluations
• Monitor patient’s
cardiorespiratory
status & oxygen
saturations
throughout the
procedure.
• Premidicate
patient for pain
control. Assess
need for further
medication
throughout the
procedure.
• Patient’s position :
– Supine
– Sit upright
– Lateral decubitus position

17. Insertion site
• Triangle of safety (Mid
Axillary line at 4th or 5th
ICS)
– Anterior border of
latissimus dorsi
– Lateral border of pectoralis
major muscle
– Line superior to horizontal
level of nipple
– Apex below axilla
• Mid clavicular line 2nd ICS

18. Procedure
1. Determine the site of
insertion. Locate the triangle
of safety; bounded by the
lateral border of the pectoris
major, 5th or 6th intercostal
space, imaginary vertical line
between the anterior and
mid axillary lines.
2. Surgically prepare and drape
the chest at the
predetermined site of the
tube insertion.
(wear sterile gloves, gown,
hair cover, face shield/
googles & apply sterile
drapes to the area)

19. 3. Locally anaesthetized
the skin and rib
periosteum.
4. Make a 2-3cm
transverse incision at
the predetermined
site and bluntly dissect
through the
subcutaneous tissues,
just over the top of
the rib.

20. 5. Puncture the parietal
pleura with the tip of
a clamp (Kelly clamp)
and put a gloved
finger into the
incision to avoid
injury to other
organs and to clear
any adhesions, clots,
etc.
6. Clamp the proximal
end of the chest
tube and advance
the tube into the
pleural space to the
desired length.

21. 7. Release the clamp
and continues 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.
8. Connect the end of
the chest tube to
the drainage
device.
9. Suture the tube in
place by using 0 or
1-0 silk or nylon
stitches.

22. 7. Remove the clothes
and clean the blood at
the incision site.
8. Apply a dressing and
tape the tube to the
chest.
9. Do a chest X ray
10. Obtain arterial blood
gas values and/or
institute pulse
oximetry monitoring
as necessary.

23. Complication
Damage to structures • Laceration or puncture of the intrathoracic and/or abdominal
organs, all of which can be prevented by using the finger technique
before inserting the chest tube.
• Damage to the intercostals nerve, artery or vein.
• Subcutaneous emphysema, usually at tube site.
Equipment • Incorrect intrathoracic or extrathoracic tube position.
• Chest tube kinking, clogging or dislodging from the chest wall or
disconnection from the underwater seal apparatus.
• Anaphylactic or allergic reaction to surgical preparation or
anaesthesia.
Failure • Introduction of pleural infection.
• Persistent pneumothorax
• Recurrence of pneumothorax upon removal of the chest tube.
• Lungs fail to expand due to plugged bronchus; bronchoscopy
required.

24. Post- procedure patient care
• Chest tubes site and dressing.
– Dressing should be dry and intact.
– Palpate for subcutaneous emphysema.
• Tubing :
– Regular inspection for leak and knink dependant loops compression/
occlusion.
• Drain fluid :
– Monitor volume, rate, color and characteristics.
• Keep drain below the level of chest.
• High or semi fowler’s position.
• Chest tube should not be clamped during movement ambutation or trips.
• Clamp only to :
– Locate air leaks
– Stimulate tube removal
– Replace a drain

25. Timing of chest tube removal
• Depends upon indications.
• Pnuemothorax :
– Bubbling movement has ceased.
– Lung fully expanded in CXR.
– If controversial :Duration of observation, clamping the
tube
– Get CXR 12- 24 hours after the last air leak.
• Pleural fluid drainage :
– If volume is <100ml in 24 hours.
– If serous fluid.
– Lung re-expanded & clinical status improved.
– No fresh or altered blood coming out of the chest tube.

26. Procedure for chest tube removal
• Gather supplies and explain
procedure to patient.
• The clinician will remove the dressing
and sutures.
• Ask the patient to inspire an hold the
breath, the clinician will remove the
chest tube in one quick movement.
• Immediately apply a sterile gauze
dressing containing petroleum to
prevent air from entering pleural
space.
• Monitor patient’s respiratory status.
• Arrange for chest X-ray to confirm
lung re-expansion.
• Monitor patient’s respiratory status
and SPO2 for 1-2 hours after removal.

27. Summary
• Chest tubes are inserted to drain blood, fluid, or air and allow full expansion of the lungs.
• The tube is placed between the ribs and into the space pleural space.
• The area where the tube will be inserted is anesthetized locally.
• The patient may also be sedated.
• The chest tube is inserted through an incision between the ribs into the chest and is connected to a bottle
or canister that contains sterile water (underwater seal).
• Suction is attached to the system to encourage drainage.
• A suture and adhesive tape is used to keep the tube in place.
• The chest tube usually remains in place until the X-rays show that all the blood, fluid, or air has drained
from the chest and the lung has fully re-expanded.
• When the chest tube is no longer needed, it can be easily removed, usually without the need for
medications to sedate or numb the patient.
• Antibiotics may be used to prevent or treat infection.
• Recovery from the chest tube insertion and removal is usually complete, with only a small scar. The patient
will stay in the hospital until the chest tube is removed. While the chest tube is in place, the nursing staff
will carefully check for possible air leaks, breathing difficulties, and need for additional oxygen. Frequent
deep breathing and coughing is necessary to help re-expand the lung, assist with drainage, and prevent
normal fluids from collecting in the lungs.