Chest Tube Insertion

Indications

• Complex pneumothorax
• Pneumothorax on positive pressure ventilation
• Haemothorax
• Large pleural effusion
• Empyema
• Chylothorax

Contraindications

• Relative:
  • Bleeding disorders
  • Coagulopathies

Complications

• Bleeding
• Organ perforation
• Intercostal neuralgia
• Tube blockage
• Subcutaneous emphysema
• Re-expansion pulmonary oedema
• Local infection and empyema

Equipment

• Sterilised chest-tube tray
• Sterile gown, mask and gloves
• Sterile drapes or towels
• Local anaesthetic
• 2% chlorhexidine solution and sterile gauze
• 25 and 21 gauge needles
• 10 mL and 20 mL syringes
• Scalpel with size 11 blade
• 4 or 5 dissecting equipment such as Kelly curved clamps or artery forceps
• Strong nonabsorbable sutures of size 1.0 or greater made of silk or nylon
• Chest tube of appropriate size
  • Stable patient: 16 to 22 french
  • Chronic lung disease, on mechanical ventilation or risk of large air leak: 24 to 28 french
• Pleural drainage system
• Petroleum based and regular gauze dressings

Method

1. Open and prepare equipment
2. Clamp the distal end of the chest tube
3. With another pair of forceps clasp the distal end of the chest tube
4. Position the patient: ipsilateral hand behind the patient’s head
5. Identify triangle of safety
   • 
   • Localise the clavicle
   • Count rib numbers when going down the anterior chest wall
   • Once finding the fourth and fifth intercostal space move laterally towards the anterior axillary line; this will be the site of incision, but the chest tube will be inserted one interspace higher
     • 
     • Mark the incision point with a pen marker
6. Apply sterile gown
7. Clean area
8. Cover with sterile drapes
9. Generously anaesthetise skin, deeper tissues, parietal pleura and periosteal surface of the rib below the insertion site
10. Make an incision 1.5-2 cm above and parallel to the anaesthetised rib
11. Use a dissecting tool (e.g. Kelly clamp) to dissect the subcutaneous tissue
12. Stay on top of the rib to guide the blunt dissection
    • 
13. Gently push the clamp into the parietal pleura or use your finger
14. Ensure the lung is not adherent to the pleura, some pleural fluid should trickle out
15. Place the tube through (using the initially distal clamp) as a guide with your finger
16. If meant to drain a pneumothorax, aim apically or if meant to drain fluid aim basally
17. Make note of the depth of tube insertion based off the numerical markings on the side
18. Suture the tube by wrapping the suture around the tube
    • 
19. Apply a petroleum based gauze dressing around the tube
20. Apply multiple sterile dressings
21. Obtain a post-insertion chest X-ray
22. Connect to the drainage system
23. Unclamp the distal end of the drain; if pneumothorax air bubbles should appear in the pleural drain otherwise if pleural fluid is being drained, pleural fluid should appear int he drain
24. Keep the pleural drainage system at least 100cm below the patient

Sources

• Dev, S.P., Simone, C., 2007. Chest-Tube Insertion. n engl j med.