this is a video in clinical medicine

from the New England Journal of Medicine

the insertion of a plural chest tube is

often done in a setting where immediate

action is required nonetheless adherence

to sterility analgesia sound technique

and safety are always warranted

the most common indications for chest

tube drainage are pneumothorax that is

recurrent persistent under tension or

bilateral any pneumothorax in a patient

on positive pressure ventilation


recurrent or symptomatic large pleural

effusion empyema and Kyllo thorax

there are relative contraindications

mainly based on hematologic

abnormalities such as bleeding diathesis

or coagulopathy blood products or

coagulation factors may need to be

transfused in order to reduce the risk

of bleeding during the procedure the

procedure should be explained and

consent obtained whenever possible from

the patient or next of kin

a chest x-ray should be performed when

possible prior to the chest tube

insertion sterilized and fully prepared

chest tube trays are often available in

the hospital the key materials required

in addition are a sterile gown mask and

gloves sterile drapes or towels local

anesthetics such as 1% lidocaine

chlorhexidine cleaning solution and

sterile pieces of gauze 25 and 21 gauge

needles 10 cc and 20 CC syringes a

scalpel with size 11 blade which should

be on the chest tube tray at least 4 or

5 dissecting instruments such as Kelly

curved clamps or artery forceps which

should also be found on the chest tube

tray non-absorbable strong sutures of

size 1.0 or greater made of silk or

nylon a chest tube of appropriate size a

sterile drainage system and dressings

for the tube after insertion the chest

tube is sized according to its internal

diameter the length of the tube is

marked with numbers to indicate distance

into the chest wall

additionally there are several drainage

holes at the distal end a radio-opaque

stripe runs along the length of the tube

and outlines the most proximal drainage

hole this is used to confirm correct

placement of the chest tube in the

pleural space on a chest x-ray choosing

the size of chest tube is based on the

indications for the tube in the case of

a large pneumothorax in a clinically

stable spontaneously breeding patient

chest tubes with an internal diameter of

16 to 22 French may be placed in a

patient with a large pneumothorax who is

clinically unstable the same rules for

chest tube sizes apply however if the

patient has underlying lung disease

requires mechanical ventilation or is

anticipated to have a large air leak

larger tubes from size 24 to 28 French

are recommended in order to drain a

viscous hemothorax or empyema or to

evacuate a pneumothorax in a patient

receiving mechanical ventilation larger

diameter tubes sized 28 to 32 French are

more often employed newer evidence


the insertion of smaller size 10 to 14

French catheters or pigtailed rings for

the drainage of new methods and

clinically stable patients and for

malignant pleural effusions this is done

using a seldinger technique with a guide

wire and often with ultrasound guidance

this technique differs from that used

for larger chest tubes and will not be

discussed further in this video once the

chest tube tray is open and all the key

instruments are identified occlude the

proximal free end of the chest tube with

a clamp or forceps next with another

clamp or forceps grasp the distal end of

the tube this will aid in passing the

tube through the tract

the patient should be positioned either

supine or in the semi recumbent position

the ipsilateral arm may be maximally

abducted to the side of the patient or

alternatively positioned behind the

patient's head in order to have optimal

exposure of the insertion site the ideal

location for the placement of a chest

tube is in the triangle of safety the

anatomical region defined by the lateral

border of the pectoralis major muscle

and kirilee the mid axillary line

posterior Li which is also the anterior

aspect of the latissimus dorsi the apex

just below the axilla and the horizontal

level of the nipple inferiorly

the nipple line may be an unreliable

landmark for female patient due to

breast tissue to help with landmarking

remember that the triangle of safety

should approximately lie between the

fourth and fifth intercostal space in

the anterior axillary line start your

landmarking by localizing the clavicle

next count the rib numbers as your

fingers traverse down the anterior chest


once the correct intercostal space is


move your hand along the space laterally

towards the anterior axillary line

the incision will be made here the chest

tube will actually be inserted one

interspace above this point mark the

incision spot with the imprint of the

back of a needle or a pen marking

once full barrier precautions are

employed use the chlorhexidine cleaning

solution and sterile gauze to create a

large sterile field on the patient's

skin cover the field with sterile drapes

so that only the procedure site is

exposed adequate analgesia is a very

important step in this procedure as

chest tube insertions can often be very

painful for the patient the skin

subcutaneous tissues deeper tissue

layers parietal pleura and periosteal

surface of the rib below the intended

insertion site must be generously

anesthetized using the smallest gauge

needle create a wheel of anesthetic in

the skin overlying the landmark spot

using the larger needle anesthetize the

subcutaneous skin layers through the

wheel aspirating as the needle moves

deeper anesthetize the periosteum of the

rib that lies below the intercostal

space where the tube will be inserted

once the parietal pleura is encountered

a flash of pleural fluid will fill the

syringe if a pleural collection is being

evacuated if a pneumothorax is being

drained the syringe may only fill with

air as the needle enters the pleural

space withdraw the needle aspirating

along the entire path

make an incision approximately 1.5 to 2

centimeters in length above and parallel

to the anesthetized rib introduce the

curved dissecting instrument such as a

Kelly clamp into the incision begin

dissecting the subcutaneous tissues in

order to reach the intercostal muscles

after dissecting through the

subcutaneous tissues stay on top of the

rib to guide the blunt dissection this

will create a diagonal path towards the

correct intercostal space

when using a larger chest tube of sizes

24 French or greater use your index

finger to explore the tract being

created by blunt dissection this is done

to ensure the larger caliber tube will

be able to pass through the tract

once you have dissected through the

subcutaneous tissues and deeper

intercostal muscle layers you will

encounter the parietal pleura

push the clamp gently through the

parietal pleura the entry into the

pleural space through the parietal

pleura is felt as a give or a sudden

release of resistance alternatively you

may use your finger to penetrate through

to the pleural space

once the pleural space is entered use

your index finger to ensure the lung is

not adherent to the chest wall which may

impede passage of the tube into the

pleural space often pleural fluid will

trickle out through the tract further

confirming entry into the pleural space

pass the tube through the incision

unclamp the jaws of the Kelly and then

direct the tube through the tract slowly

using your finger as a guide

if the tube is meant to evacuate a

pneumothorax Amite apical e towards the

top of the lung if the indication is to

drain fluid

Ament basally towards the bottom of the

lung make note of the depth the tube has

passed by keeping track of the numerical

markings on the side of the tube

secure the chest tube to the skin using

the heavy sutures simple interrupted or

mattress sutures are often satisfactory

to ensure stability of the tube and

avoidance of air leaks around the tube

the free ends of the sutures are wrapped

around the tube and tied multiple times

to secure it in place

purse string suture z' are not

recommended as they yield poor cosmetic

results and increase the risk of skin

necrosis once the chest tube has been

secured a petroleum-based gauze dressing

should be wrapped around it

apply several pieces of sterile gauze

around the tube secure the site with

multiple pressure dressings a chest

x-ray must be done to confirm correct

placement on an x-ray the radio-opaque

stripe is visible with an interruption

indicating the position of the proximal

hole this hole must be within the

pleural space otherwise it is sitting

outside the pleura and not draining

effectively this is an indication to

replace the tube altogether do not

advance the tube into the chest as this

can introduce non sterile tubing into

the chest cavity

before unclamping the free end of the

chest tube firmly connected to the

sterile drainage system now unclamp the

free end if pleural fluid is being

drained the fluid level in the drainage

system will rise if a pneumothorax is

being evacuated air bubbles will appear

do not reclaim the chest tube while

there is bubbling this may lead to

recollection of a pneumothorax and may

even result in a tension pneumothorax

most commercially available drainage

systems use the three bottle model of

closed drainage and suction the most

important bottle is the underwater seal

which serves as a one-way valve that

allows air and fluid to leave the

pleural cavity without the risk of

reentry during inspiration all available

pleural drainage systems contain the

underwater seal bottle bubbling may be

seen in this bottle this will indicate

whether there is an ongoing air leak

either from the patient or from the

system itself the two other bottles that

may be present in the drainage system

are a collection bottle connected

directly to the patient for accumulation

of pleural fluid and/or debris and a

suction system that connects to wall

suction but regulates the amount of

suction actually delivered to the

pleural space via a column of sterile

water suction may be applied if there is

a persistent pneumothorax

despite the underwater seal or if a

viscous pleural collection is not

draining effectively when evacuating

chronic large pleural effusions the risk

of re expansion pulmonary edema has been

well described a stepwise approach to

the drainage of chronic large pleural

effusions is recommended not exceeding 1

to 1.5 liters within a 30 minute period

the pleural drainage system must be kept

approximately 40 inches below the

patient in order to prevent retrograde

flow of air or fluid back into the

pleural space

there are complications associated with

the insertion of a chest tube

these include bleeding and hemothorax

traumatic perforation of the lung heart

chambers diaphragm or intra abdominal

organs intercostal neuralgia due to

trauma of the intercostal neurovascular

bundle intermittent blocking of the tube

with clot or debris subcutaneous

emphysema reexpansion pulmonary edema

due to more than 1 to 1.5 liters of

fluid drainage in less than 30 minutes

infection of the drain site and empyema

the timing of chest tube removal depends

on the indications for the chest tube in

the case of a pneumothorax

bubbling must have ceased the patient

stabilized clinically and the lungs

re-expanded on a chest x-ray as a

minimal criteria to remove the tube if

suction is being applied to evacuate the

pneumothorax most clinicians perform a

trial of underwater seal alone in order

to ensure there is no further bubbling

with the suction turned off

most physicians will perform a chest

x-ray 12 to 24 hours after the last

evidence of an air leak prior to

removing the tube the decision to clamp

the chest tube to check for a persistent

air leak is one that is practitioner

dependent and there is insufficient data

to support or refute this practice if

the chest tube was placed to drain

pleural fluid once the drainage volume

is less than 200 CCS and a 24-hour

period and the fluid is serous the tube

may be removed if a chest tube was

placed for empyema removal of the tube

should be considered only after the

patient has stabilized clinically and

the drainage criteria are met if an air

leak is persistent or the pleural fluid

drainage criteria are not met a

pulmonary specialist or thoracic surgeon

should be consulted for more definitive

potentially surgical management

pneumothorax risk is no different after

chest tube removal cheering and

inspiration vs. and expiration once the

sutures are removed instruct an awake

patient to hold his or her breath either

after a full inspiration or full

expiration or while performing a

valsalva maneuver pull the tube at end

expiration if a patient is being

mechanically ventilated ideally two

clinicians should be present during tube

removal once the tube is removed quickly

seal the incision site with a

petroleum-based gauze reinforced with

several pieces of regular gauze on top

of it secure the site with a pressure

dressing additional sutures may be

required to close the incision a

follow-up chest x-ray should be obtained

12 to 24 hours after the tube has been

removed closely inspect for any

suggestion of a new pneumothorax caution

must be exercised when removing a chest

tube from any patient on a mechanic

ventilator especially in those with high

oxygen or positive pressure requirements

chronic lung disease or other risks for

recurrent pneumothorax experienced

physicians should supervise the decision

to remove the tube in these cases the

insertion of a chest tube is often done

under extremely critical circumstances

however using the appropriate techniques

and sterile precautions will ensure safe

and efficient performance