Chest Tubes (Tube Thoracostomy)

Pneumothorax

• Large or symptomatic primary spontaneous pneumothorax
• Any secondary pneumothorax (COPD, ILD, etc.) that is moderate/large, symptomatic, or under positive-pressure ventilation
• Traumatic pneumothorax, especially with hemothorax or mechanical ventilation
• Tension pneumothorax after emergent decompression (needle or finger thoracostomy) as definitive management

Hemothorax / Hemopneumothorax

• Traumatic hemothorax of any significant size
• Post-op thoracic bleed
• Diagnostic and therapeutic drainage to quantify rate of bleeding

Pleural Effusion

• Complicated parapneumonic effusion / empyema (pH < 7.2, LDH high, frank pus)
• Malignant effusion requiring ongoing drainage
• Symptomatic large effusion (especially ICU patients with respiratory compromise)

Post-surgical or Iatrogenic

• After thoracic, cardiac, upper abdominal surgery
• Persistent air leak or significant pneumothorax after procedures (lung biopsy, central line, barotrauma, etc.)

Absolute (or Near-Absolute)

• No consent and non-emergent indication
• Chest wall infection at proposed insertion site → choose alternate site if possible
• Known diaphragmatic rupture with herniated abdominal contents at planned site (e.g., CT evidence)

Relative Contraindications

• Significant coagulopathy or thrombocytopenia (INR > 1.5, plt < 50k) – correct where possible but do not delay for unstable tension/hemothorax
• Dense pleural adhesions / previous thoracic surgery on that side – higher risk of injury/malposition
• Morbid obesity / distorted anatomy – use ultrasound where possible
• Very large, chronic effusion or long-standing pneumothorax → high REPE risk; consider staged drainage and lower suction initially

The "Safe Triangle"

The safe triangle is the preferred insertion site for chest tubes:

Borders:

• Anterior: Lateral border of pectoralis major
• Posterior: Anterior border of latissimus dorsi
• Inferior: Line at or just above 5th intercostal space (roughly nipple line in males)
• Superior: Axilla

Key Anatomical Points

• Insert above the rib (superior border) to avoid the neurovascular bundle running along the inferior rib margin
• Aim the tube apically and posteriorly for air, basally and posteriorly for fluid
• In supine or semi-recumbent ICU patients, most air collects anteriorly/superiorly, fluid posteriorly/basally – but external access is still in the safe triangle; the trajectory differs

Tube Types

Traditional Large-Bore Chest Tube (20–36 Fr)

• Blunt dissection insertion
• Best for trauma hemothorax / hemopneumothorax where clot and high-volume blood are expected

Small-Bore / Pigtail Catheter (8–16 Fr)

• Seldinger/over-wire technique
• Very effective for simple pneumothorax or non-viscid effusions
• May be initial choice for malignant effusion/empyema per BTS 2023 guidance

Typical Size Choices (Adult)

Drainage System

Modern disposable systems (e.g., Atrium Oasis/Ocean) consist of:

• Collection chamber: Measures output
• Water-seal chamber: One-way valve, tidaling, bubbling
• Suction chamber or dial: Sets negative pressure (e.g., –20 cm H₂O)

1. Assessment & Imaging

Confirm indication and side:

• CXR, CT, or bedside ultrasound as available

Assess:

• Hemodynamics, oxygenation, ventilation
• Coagulation profile and platelet count (if time)
• Note prior thoracic surgery / radiation / chest deformity → higher malposition risk

2. Analgesia & Sedation

Local anesthesia infiltrated:

• Skin, subcutaneous tissue, periosteum of rib above, then intercostal muscles and pleura
• Lidocaine 1–2% (watch max dose)

Systemic analgesia:

• IV opioid (e.g., fentanyl, hydromorphone)

Sedation:

• Light–moderate sedation (e.g., midazolam, propofol, ketamine) titrated to patient and setting
• Mechanically ventilated patients may need deep sedation ± NMB to prevent bucking during insertion

3. Positioning

• Best: 45° semi-recumbent, arm on affected side abducted and placed behind head to open intercostal spaces
• Alternative: Lateral decubitus with affected side up (OR / certain ICU setups)

4. Sterile Prep

Full maximal sterile barrier ideally:

• Cap, mask, sterile gown and gloves, full chest drape
• Wide chlorhexidine prep over anterior and lateral chest wall

(Non-crashing, adult, large-bore tube via safe triangle)

Step 1: Mark Site

4th–5th ICS in the mid- to anterior-axillary line within the safe triangle.

Step 2: Local Anesthetic

Raise a skin wheal, then infiltrate along planned tract down to pleura.

Step 3: Small Skin Incision

2–3 cm, parallel to the rib, centered over the superior edge of the rib below the intended ICS.

Step 4: Blunt Dissection

Use Kelly/Curved clamp:

• Spread through SC tissue, then over rib and through intercostal muscles
• Always keep tip on superior rib border

Step 5: Enter Pleural Space

• You'll feel a "give" as you push through parietal pleura
• Open clamp jaws and spread to enlarge the opening

Step 6: Finger Thoracostomy

Insert gloved finger into the space:

• Confirm lung position, lysis of local adhesions, absence of diaphragm/bowel right at site
• Ensure you feel free pleural space

Step 7: Guide Tube In

Grasp the fenestrated tube end with clamp; advance along your finger track into pleural space.

Direct:

• Posterior–apical for air
• Posterior–basal for fluid

Ensure all fenestrations are inside; check depth markings.

Step 8: Connect to Drainage System

• Immediately connect to primed water-seal system
• Remove clamps once the system is ready to avoid open pneumothorax

Step 9: Secure the Tube

• Heavy nonabsorbable suture (e.g., 0 or 1-0 silk/nylon)
• Use a stay suture that can also be used to close after removal
• Apply occlusive dressing (e.g., petroleum gauze + large Tegaderm)

Step 10: Confirm Placement

• Observe tidaling and expected bubbling
• Obtain post-insertion CXR as soon as feasible

Initial Setup

Water Seal Chamber

• Fill to manufacturer's mark (usually 2 cm)
• Acts as one-way valve – expect tidaling with respiration

Suction

• Connect to wall suction and set regulator (commonly –20 cm H₂O)
• Remember: The suction dial, not wall vacuum number, determines negative pressure

Interpreting the System

Tidaling in Water Seal

• Present: Likely in pleural space and not fully expanded
• Absent: Consider kink, obstruction, lung fully expanded, or tube against lung

Bubbling

• Early, intermittent bubbling during expiration or coughing is normal in pneumothorax
• Continuous vigorous bubbling suggests significant air leak (from lung, tube connections, or system)
• Use "bubbling when clamped" method to localize leak (starting at patient and moving downstream)

Output

Document volume, character, and rate:

At the Bedside

Assessment Frequency

At least q1–2 hrs in ICU initially; more routine on stable floor patients.

Check:

• Insertion site & dressing (bleeding, air leak, infection, subQ air)
• Tube path (no kinks, dependent loops)
• Drainage system position (below chest, upright, not knocked over)
• Tidaling and bubbling pattern
• Total output and trend

Transport

• Keep system below chest level
• Do not clamp a chest tube with an active air leak unless absolutely necessary and you understand the risk of tension
• If temporary disconnection occurs, place the tube end in sterile water until reconnected

Troubleshooting (High-Yield)

When Is It Ready to Come Out?

Underlying issue resolved or improving:

• CXR or ultrasound shows re-expanded lung / minimal effusion

Output acceptable (institution-specific rules):

• Serous fluid <150–200 mL/24 hr
• No gross blood / pus

Air leak resolved:

• No bubbling at water seal during spontaneous breaths / cough for 12–24 hrs

Patient can be monitored for recurrent pneumothorax/effusion after removal.

Removal Steps

1. Explain & Pre-medicate

IV/PO analgesia; sometimes anxiolytic

2. Position

Head of bed at 30–45°, patient supine or semi-recumbent

3. Remove Dressing and Sutures

Keep stay suture ready if placed

4. Breath-Hold Strategy

Options:

• End-expiratory pause
• Valsalva maneuver (deep breath in and bear down)

Goal: Minimize air entrainment

5. Remove Tube

During breath hold, pull tube out in one smooth motion. Immediately occlude with occlusive dressing (e.g., petroleum gauze) and tie stay suture if present.

6. Post-Removal Monitoring

• Vitals, oxygenation, breath sounds
• Follow-up CXR based on local policy (often within 2–4 hrs or sooner if symptomatic)

Immediate / Early

Malposition

In subcutaneous tissue, fissure, mediastinum, abdomen, or lung parenchyma

Vascular Injury

Intercostal vessels, internal mammary, large thoracic vessels (rare but catastrophic)

Lung Laceration

Can worsen air leak, bleeding

Diaphragm / Abdominal Organ Injury

Liver, spleen, stomach, bowel – especially if tube inserted below recommended ICS or in very obese patients

Persistent Pneumothorax / Air Leak

Due to lung pathology (bronchopleural fistula), malposition, or tube dysfunction; persistent leak >48 hrs often prompts CT and/or surgical consultation

Re-expansion Pulmonary Edema (REPE)

Prevention:

• Avoid very negative suction at first in chronic, large effusions/pneumothoraces
• Consider staged drainage (e.g., clamp/stop after 1–1.5 L, reassess)

Management:

• Supportive: oxygen, NIV/ventilation, conservative fluid strategy, maybe diuretics
• Treat like other non-cardiogenic pulmonary edema

Late Complications

• Infection / empyema / site infection
• Chronic pain or neuropathic pain (intercostal nerve injury)
• Tube blockage / retained hemothorax → VATS
• Scarring / cosmetic issues at insertion site

A Heimlich valve is a small, specially designed flutter valve that is portable and mobile, allowing the patient to ambulate with ease.

• Attaches to the chest tube at one end and a drainage bag at the other
• The drainage bag allows air and fluid to escape but prevents their re-entering the pleural space
• Can be worn under clothing
• Functions in any position, never needs to be clamped
• Can be hooked up to suction if required

Trauma Hemothorax

• Aim for large-bore (≥28 Fr) unless your trauma team has adopted small-bore protocols
• Massive output criteria (e.g., >1500 mL initial or >200 mL/hr) → surgical consult for thoracotomy
• If significant residual blood on imaging despite functioning tube, early VATS is preferable to a second tube

Spontaneous Pneumothorax

• BTS and other guidelines increasingly support small-bore / ambulatory systems in selected patients
• Ventilated / unstable → lower threshold for formal chest tube vs aspiration alone

ICU Pleural Effusions

• Consider ultrasound-guided pigtail catheter for effusions, especially if coagulopathy or frailty
• Several societies now endorse this as first-line

Anticoagulated Patients

• If time allows, correct coagulopathy (platelets, reversal, etc.)
• Use smaller-bore catheter + ultrasound guidance when appropriate to decrease bleeding risk
• Balance risk of bleed vs risk of ongoing tension/respiratory failure – in true emergencies, drain first

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