Chest Tubes: Insertion Assist and Drainage

Chest tube time-critical points: drain size, the hemothorax surgical threshold, the suction ceiling and the lidocaine limit.

A chest tube (tube thoracostomy) is a flexible drain. It goes through the chest wall into the pleural space. It clears out air, blood, pus or fluid so the lung can re-expand. The pleural space can then return to negative pressure.

How It Works

• One-way drainage: Gravity or low-pressure suction moves air and fluid out of the pleural space. The sealed system keeps the flow one way.
• Three chambers: The collection chamber measures output. The water-seal chamber stops backflow. The suction control sets any negative pressure.
• Tidaling: Watch the water-seal tubing. Fluid there swings with each breath when the lung is connected and the tube is open.
• Air leak: Continuous bubbling in the seal chamber means air is escaping. It is coming from the lung or from somewhere in the system.
• Heimlich valve: A one-way flutter valve can replace the bottle for pneumothorax. The three-chamber unit is for fluid and air, as a 2025 emergency medicine review notes.

Where It Fits

The chest tube is the definitive drain for significant pneumothorax, traumatic hemothorax, complicated effusion and empyema. Smaller or diagnostic collections suit thoracentesis (needle or catheter drainage). That technique is covered under Alternative Technique. Let the indication pick the size: small bore for most patients, large bore for unstable trauma. For UK practice, the main sources are the BTS 2023 guideline and clinical statement. US teams should also apply their protocol.

Indications

• Pneumothorax: large or symptomatic, with a large air leak, or occurring on positive-pressure ventilation.
• Traumatic hemothorax or hemopneumothorax: Drain it and measure the output. Large bore for unstable patients.
• Pleural infection or empyema: For initial drainage, small bore is usually the first choice.
• Tension physiology: Decompress first, per protocol. The chest tube is the definitive drain after that.

Absolute Contraindications

Nothing counts as an absolute contraindication when the drain is life-saving: tension physiology or massive hemothorax. Otherwise, do not insert through infected skin. Choose another site.

Relative Contraindications & Cautions

• Coagulopathy or antithrombotic therapy: Weigh the bleeding risk against the indication. Fixing the clotting must not hold up decompression or drainage of tension or massive hemothorax.
• Prior thoracic surgery or dense adhesions: Expect a higher risk of malposition. Plan the site with imaging and ultrasound.
• Posterior approach: Avoid it. The lower rib margin does not cover the neurovascular bundle.

Consider an Alternative

A small or diagnostic effusion may only need thoracentesis. See Alternative Technique under Step-by-Step Procedure.

Abort / Stop Criteria

• Pain or chest tightness: slow or stop the drainage.
• No ultrasound for a pleural fluid procedure: hold the fluid procedure until ultrasound is available.

Team Roles During the Procedure

• Operator: Selects the site, makes the incision and places the drain.
• Assistant: Positions the patient, holds the drain and keeps the field sterile.
• Medication clinician: Prepares local anesthetic and sedation or analgesia per order and counts the lidocaine total.
• Monitor and recorder: Tracks SpO₂, ECG and blood pressure, and records the time, drain size and output.

1. Triangle of Safety

1. Image the side: Confirm the side, the size of the collection and the depth to the pleura on X-ray or ultrasound.
2. Mark the site: Between the anterior axillary and mid-axillary lines, at or above the 5th intercostal space.
3. Insert above the rib: Keep the tract above the rib margin to avoid the neurovascular bundle.
4. Confirm the tract: Keep the drain in the chosen direction and check that side-holes are inside the chest.

Pediatric

Same landmarks, scaled to size. Weight sets the drain size, the needle and the sedation, per the pediatric protocol. See Special Populations.

Equipment

Sizing

Small bore, 14 Fr or smaller, suits most indications, empyema included. Larger drains are generally associated with more pain. Large bore is the custom for unstable trauma with hemothorax. Pick the size by indication and local protocol.

Patient Positioning & Preparation

Position the patient to open up the intercostal space. Place the arm where the operator directs. Monitor SpO₂, ECG and blood pressure the whole time. Give sedation and analgesia per protocol.

These are typical adult and pediatric references. Check them against local protocol and the current drug label. Doses vary by protocol; follow local protocols and medical direction.

Opioid plus benzodiazepine: used together, they raise the risk of respiratory depression (FDA boxed warning). Keep naloxone and bag-mask ventilation within reach. Flumazenil is not routine. See naloxone and flumazenil.

Prophylactic antibiotics: EAST 2022 gives a conditional recommendation for antibiotic prophylaxis at insertion. The group in view is adult trauma patients who need a tube, and the aim is fewer empyemas. Follow the trauma protocol.

Drainage Settings

Phase 1: Prepare

1. Confirm the indication and side: Review imaging for side, size and type of collection. Use ultrasound before any fluid procedure.
2. Check bleeding risk: Check coagulation status and antithrombotic use per protocol. Do not delay life-saving drainage.
3. Prepare the unit: Select drain size by indication. Assemble and seal the three-chamber unit or valve, and set suction only as ordered.

Phase 2: Perform

4. Position and monitor: Open the intercostal space and monitor SpO₂, ECG and blood pressure. Give sedation and analgesia per protocol.
5. Prepare the field: Clean and drape per protocol. Infiltrate local anesthetic down to the pleura and count the total dose.
6. Mark the site: Triangle of safety, at or above the 5th intercostal space.
7. Make the skin incision: Make a small incision at the marked site, sized to the drain.
8. Enter the pleura above the rib: Use the blunt or wire-guided method your operator is trained in and that suits the drain type.

9. Direct the drain: Aim the tube toward the collection and confirm the side-holes are inside the chest wall.
10. Connect and fix: Connect to the unit below chest level and secure the drain with a holding suture.

Phase 3: Confirm & Secure

11. Check tidaling and bubbling: Confirm swinging in the seal chamber and document any bubbling (see Confirmation & Monitoring).
12. Order the chest X-ray: Obtain it within a few hours of insertion to confirm position.

Alternative Technique: Ultrasound-Guided Thoracentesis

1. Map the pocket: Use ultrasound to confirm the pleural fluid and its depth. Ultrasound guidance is required before pleural fluid procedures.
2. Choose the needle: A small-bore diagnostic needle (often 21G/40 mm) is typical. For therapeutic aspiration, use a catheter per local protocol rather than a needle.
3. Insert above a rib: Aspirate slowly by syringe or gravity. Vacuum bottles and wall suction are not used.
4. Limit the volume: Stop at 1.5 L in one attempt, or sooner for chest tightness, pain, persistent cough or worsening breathlessness.

Primary Confirmation

The primary confirmation is tidaling (respiratory swinging) in the water-seal tubing, backed by the lung re-expanding on chest X-ray.

Secondary Confirmation

• Bubbling: Intermittent bubbling or none is expected. Chart it alongside the breathing pattern.
• Output: Measure the volume and colour at the frequency ordered.
• Skin: No spreading subcutaneous air around the site.

Ongoing Monitoring

• Daily: Check the wound for infection, drainage volume, and respiratory swinging or bubbling. Chart them.
• Each move: Recheck the tubing, the seal and the unit height.
• Each shift: Confirm the holding suture and the clamp status.

Every chest drain comes with risk. Organ puncture is uncommon. Reported rates differ a lot between series and techniques.

Pediatrics

• Drain and needle: Size by weight per the pediatric protocol. See Equipment Sizing.
• Lidocaine: The label maximum varies by age and weight (label example: 5 years, 23 kg, 75–100 mg, or 3.3–4.4 mg/kg). Follow the pediatric protocol and Weight-Based Dosing.
• Sedation and analgesia: Weight-based per protocol. Monitor continuously.
• Drain size not set on this page: No pediatric drain size, insertion depth or sedation dose appears on this page. Go by the pediatric protocol and sizing tape (see Broselow).

Mechanical Ventilation

• Pneumothorax on ventilation: On the ventilator, larger-bore drains are often used, per local protocol.
• CPAP or high positive pressure: Before CPAP or high positive pressure, an open, functional drain should already be in place.

Pregnancy

• Site: As pregnancy advances, the diaphragm sits higher. Plan the site and tract with ultrasound or X-ray. Confirm position afterwards, per protocol.

Trauma

• Unstable patients: Large bore is the custom. Follow the output thresholds in Key Numbers, and call surgery early if the patient is unstable.
• Blood loss: Manage hemorrhage per the trauma protocol alongside drainage.
• Related procedures: Needle decompression, finger (simple) thoracostomy and open pneumothorax management are not covered on this page. Use the trauma and airway protocol for them.

Chronic Lung Disease

• High-flow oxygen: Check an arterial blood gas after starting, to exclude rising PaCO₂, per local oxygen protocol.

Immediate Aftercare

• X-ray: Confirm position on chest X-ray within a few hours of insertion.
• Analgesia: Prescribe analgesia before the procedure ends, per protocol.

Ongoing Maintenance

• Flushes: Small-bore drains: flush with normal saline as prescribed. Volume and interval follow local protocol.
• Fixation: Keep the holding suture secure and the drain free of kinks.
• Stripping or milking: Not routine. Only do it when the specialist orders it.
• Charting: Daily site, volume and swinging or bubbling checks.

Drain Removal

• Who decides: Removal follows a specialist order or the protocol. The decision rests on output, air leak and imaging.
• Technique: Follow the protocol for breathing phase, suture management and an occlusive dressing.
• After removal: Chest X-ray and site checks per protocol.

Transport Considerations

• Keep it open: Do not clamp a bubbling drain for transport unless a specialist orders it.
• Height: Keep the unit below chest level.
• Valve versus unit: The Heimlich valve is for pneumothorax, not for hemothorax, a large air leak or infected fluid. It can clog or fail with blood or fluid. Measure fluid output with the three-chamber unit (2025 emergency medicine review). Treat the one RCT as limited evidence (n=40, primary spontaneous pneumothorax, 28 Fr tubes).
• Air transport: Gas expands as altitude rises (Boyle's law). An undrained pneumothorax, or gas in the drain system, can grow in flight. Drain an undrained pneumothorax before flight, per protocol. Keep the drain open and never clamp it. Keep the unit below the chest. Check the fluid level, fixation and connections before flight and at each altitude change. Valves and units can behave differently with cabin pressure changes. Follow the program's aeromedical protocol.
• Dislodgement en route: Cover the site per protocol and call for urgent review.

Pearls

• Tidaling is the bedside sign: A swinging seal means an open tube, connected to the lung.
• Bubbling says leak, not failure: Check whether it changes with coughing or breathing.
• Keep the drain open: Clamping is the specialist's call.
• Count the lidocaine: Each infiltration adds to the same total.
• Size follows the question: Small bore for most patients. Large bore for unstable trauma.

Common Pitfalls

• Clamped for transport → keep open unless ordered.
• No bubbling read as success → check tidaling and the whole tube.
• Suction from insertion → low pressure, not early, never above −20 cm H₂O.
• Holding suture unchecked → check it at every handover.

Skill Maintenance

• Set-up drill: Assemble and check the unit and water seal at the start of each shift.
• Simulation: Practise drain troubleshooting: loss of tidaling, continuous bubbling and dislodgement.
• Debrief: Review each drain event and any output-threshold trigger.