Tube Thoracostomy
A Self-Directed Learning Module
Technical Skills Program
Queen’s University
Department of Emergency Medicine
Introduction
Tube thoracostomy is used to evacuate an abnormal
accumulation in the pleural space. The procedure may be
performed under emergent or non-emergent conditions.
Conditions that may require treatment with a tube
thoracostomy include pneumothorax, pleural effusions,
empyema or chylothorax. Trauma is a common indication
due to accumulations of blood or air in the pleural
space.
Objectives
 Describe the indications for a tube thoracostomy
 Describe the contraindications for a tube
thoracostomy
 Describe the equipment and preparation necessary
to perform this procedure
 Describe the steps for the insertion of a chest
tube
 Describe potential complications of this procedure
and relevant prevention and management strategies
Indications
Emergency
Pneumothorax
 In all mechanically ventilated patients
 Large or symptomatic pneumothorax
 Clinically unstable patient (hypotension,
increasing O2 requirements)
 Tension pneumothorax after needle decompression
 Pneumothorax secondary to chest trauma
Hemopneumothorax (e.g. post-trauma)
Esophageal rupture with gastric leak into pleural space
Non-Emergency
Malignant pleural effusion
Treatment with sclerosing agents or pleurodesis
Recurrent pleural effusions
Complex parapneumonic effusion or empyema
Chylothorax
Post-op care
Contraindications
Absolute: Published guidelines state there are no
absolute contraindications for drainage via tube
thoracostomy except when a lung is completely adherent
to the chest wall throughout the hemithorax, or upon
patient refusal.
Relative: Risk of bleeding due to coagulopathies or
anticoagulation medications. Whenever possible,
coagulopathies and platelet defects should be corrected
with the infusion of blood products prior to the
procedure. Other relative contraindications include
multiple pleural adhesions, emphysematous blebs, and
scarring.
Equipment
These days, most hospitals have presterilized chest
tube insertion kits available for use. You should be
familiar with the kits at your institution before you
are required to use one in an emergency situation. The
key materials typically included in these kits are:
 CSR, wrap
 #10 scalpel
 13x19 inch drape (2)
 22-gauge needle (2)
 #0 suture
 Crile forceps (2)
 needle holders (2)
 non-absorbent towel (4)
 4"x4" gauze (10)
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10mL syringe (2)
25-gauge needle (1)
bag (1)
Rochester-Pean forcep (2)
cup (2)
sponge forcep (1)
18-gauge needle (1)
tray (1)
dressing scissors (1)
tissue forcep (1)
Other equipment you will need includes:
 equipment for universal precautions: gloves, gown,
mask and cap
 chest tube of appropriate size
 a commercially available pleural drainage system
should be ready for connection after the chest
tube is inserted with sterile water for water seal
 local anesthetic
 adhesive tape- cloth backed
 hard plastic serrated connectors (only for chest
tubes <24Fr, connectors for 24Fr or greater are
included in the pleurevac system)
The Chest Tube
Chest tubes are sized according to internal diameter in
the French (Fr) unit. The length of the tube is marked
with numbers to indicate distance inserted into the
chest wall. Note that they are numbered relative to the
the chest, not to the drainage hole on the chest tube.
Located at the distal end of the tube are several
drainage holes. 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 tube in the pleural space on CXR postinsertion.
Selecting the Chest Tube Size
Generally, chest tubes are No. 24 to 36 Fr for adults
and No. 16, 20 24 Fr for children. However, the size of
chest tube selected may also depend on the indication
for chest tube insertion. The table below provides a
summary of size recommendations based on indication.
Preparation
Check coagulation status and obtain consent for nonurgent tubes. Patients should be started on nasal
oxygen and placed on continuous pulse oximetry
monitoring. Place the patient in a supine or semirecumbent position with their ipsilateral arm behind
their head. Ideally, the head of the bed should be
elevated 30 to 60o. This lowers the diaphragm and
decreases the risk of injury to the diaphragm, spleen,
or liver.
The ideal insertion site is approximated by the fourth
to fifth intercostal space in the anterior axillary
line at the horizontal level of the nipple. This area
is within the "triangle of safety" (pictured below),
outlined medially by the lateral border of the
pectoralis major anteriorly, laterally by the midaxillary line and the 4th to 5th intercostal space
inferiorly. The apex of the triangle is located just
below the axilla. Note: the nipple line may be an
unreliable landmark for the interior border of the
triangle in women due to the presence of breast tissue.
Always avoid the breast tissue, even in prepubescent
girls.
Landmark this site by first locating the patient's
clavicle. Move your fingers downwards counting the ribs
as you go. Once you have located the 4th to 5th
intercostal space, move laterally to 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 site.
Anesthetizing the Tissues
Full barrier precautions must be used during this
procedure (sterile gown, gloves, protective eyewear and
a face mask).
1. Using antiseptic solution and gauze, create a large
sterile field over the marked incision site
2. Cover the field with sterile drapes, leaving the
procedure site exposed
3. The skin, subcutaneous tissues, parietal pleura,
and periosteum of the rib below the intended
insertion site (ie. the rib above the marked
incision site) must be adequately anesthetized. Up
to 7mg/kg of locally injected 1% lidocaine with
epinephrine (1:100,000) can be used (up to 5mg/kg
if not using epinephrine). Using a small gauge
needle (i.e. >25 gauge), create a wheal of
anesthetic in the skin overlying the landmarked
spot where the incision will be made.
4. Using the larger gauge needle (i.e. 20-22 gauge),
anesthetize the subcutaneous tissues through the
wheal, aspirating as the needle moves deeper.
5. Anesthetize the periosteum of the rib that lies
below the intercostal space where the tube will be
inserted
6. Once you have reached the parietal pleura, 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. Withdraw the needle, aspirating along
the entire path. If air or fluid are not found, the
insertion site should be changed.
Note: Insertion of a chest tube can be extremely
painful, a common error is inadequate local
anesthesia; another error is to forget that
additional anesthetic may be required throughout the
procedure.
Incision and Dissection
1. With the scalpel, create a 1.5 to 2cm incision
through the skin at the marked incision site
2. With a curved blunt dissecting instrument (e.g.
Kelly clamp), dissect the subcutaneous tissues
until the intercostal muscle layer is reached
3. Staying on top of the rib to avoid the
neurovascular bundle running along the inferior rib
margin, guide the blunt dissecting instrument
upwards, towards the insertion site. This will
create a diagonal path for the chest tube which is
thought to provide a better seal against air leaks
4. If using a larger caliber chest tube (24-Fr or
greater), use your index finger to explore the
tract created by the instrument, this will ensure
that the tract will be large enough to accommodate
the larger tube
5. Once you have reached the parietal pleura, push the
clamp gently through the parietal pleura, you
should feel a "give", or a release of resistance.
Ensure that adequate local anesthesia is attained
prior to proceeding with this step. Alternatively,
you may use your finger to advance into the
parietal space. Often, pleural fluid may trickle
out through the tract
6. Once you have gained access to the pleural space,
use your index finger to make sure the lung is not
adherent to the pleural wall as this would impede
the passage of the tube. If possible, leave your
finger in the tract as a guide for the tube
7. Clamp the free end of the tube
8. Using your finger as a guide, pass the tube into
the pleural space. This allows you to feel the tube
entering the pleural space and avoid subcutaneous
dissection with the tube. Some clinicians prefer to
pass the tube alone, others recommend that the tube
be held in a large curved clamp, with the tube tip
protruding from the jaws. Whichever way you choose,
it is important to remember that you should NEVER
force a tube into the pleural space!
9. If the tube is meant to evacuate a pneumothorax,
aim it apically. If the tube is meant to evacuate
fluid, aim it basally
10. Make note of the depth of tube insertion via the
numbers marked on the tube
Securing the Tube
1. Secure the tube to the patient's skin with the
heavy sutures using simple interrupted or mattress
sutures. Purse string sutures are not recommended
due to poor cosmetic results and increased risk of
skin necrosis
2. The free ends of the sutures are wrapped around
the tube and tied multiple times to secure it in
place. It must be tied tight enough so that the
tube is slightly kinked, but not so tight as to
snap the thread.
3. After securing the tube, wrap the tube with a
petroleum based gauze dressing
4. Apply several pieces of sterile gauze cut in a "Ycut" fashion around the tube with the Y-cuts at
90o angles to each other
5. Secure the site with multiple pressure dressings
6. A CXR must be done to ensure the correct placement
of the tube. On x-ray:
 The radiopaque stripe should be visible, with
an interruption indicating the placement of
the proximal drainage hole, this hole must be
within the pleural space
 If the interruption lies outside the pleural
space, the tube is not draining effectively.
In this instance, the tube must be removed and
replaced altogether. DO NOT ADVANCE THE TUBE
INTO THE CHEST! This will introduce nonsterile tubing into the chest cavity
Pleural Drainage System
Most commercially available pleural drainage systems
use the three bottle model of closed drainage and
suction. The most important bottle, the underwater
seal, serves as a one-way valve that allows air and
fluid to leave the pleural cavity without the risk of
re-entry during inspiration. Bubbling in this bottle
indicates an on-going air leak, either from the patient
or from the system itself. The other two bottles
typically contained in drainage systems are: the
collection bottle, which is 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. The pleural drainage system must be kept
approximately 40 inches (100cm) below the level of the
patient in order to prevent retrograde flow of air or
fluid back into the pleural space.
1. Firmly connect the free end of the chest tube to
the sterile drainage system and secure with tape to
prevent accidental disconnection
2. Unclamp the free end of the chest tube
3. If pleural fluid is being drained, the fluid level
in the drainage system will rise
4. If a pneumothorax is being evacuated, air bubbles
will appear in the underwater seal bottle. DO NOT
re-clamp the chest tube while there is bubbling as
this may lead to recollection of a pneumothorax and
may induce a tension pneumothorax
5. Suction may be applied if there is a persistent
pneumothorax despite the underwater seal or if a
viscous pleural collection is not draining
effectively. Usually the suction level is set to
20cmH2O at the Pleurevac
6. To avoid re-expansion pulmonary edema when
evacuating chronic large pulmonary effusions, avoid
collection of 1.5 L or more within a 30 minute
period
Complications
As with all procedures, there are risks associated with
the insertion of a chest tube. You should be familiar
with the potential complications associated with chest
tube insertion, as well as relevant preventative and
management strategies.
Self-Assessment Questions
Question 1
Which of the following features of pleural drainage
systems indicate an active air leak?
a. bubbling in the water seal chamber
b. bubbling in the collection chamber
c. fluctuation of water in the water seal chamber with
respirations
Question 2
Which of the following is an absolute contraindication
to chest tube placement?
a. parenchymal scarring
b. lung adherent to chest wall throughout the
hemithorax
c. patient taking anticoagulation medication for
greater than 6 months
d. patient has stage 4 lung cancer
Question 3
Which of the following statements regarding the chest
tube is correct?
a. chest tubes are sized according to their external
diameter in French (Fr) units
b. chest tubes sized 28-36 Fr are most appropriate for
children
c. the radio-opaque stripe runs the length of the tube
and outlines the proximal drainage hole
d. the radio-opaque stripe runs the length of the tube
and outlines the distal drainage hole
Question 4
The incision site overlies the rib below the intended
insertion site
True False
Question 5
Choose the INCORRECT statement
a. when confirming the correct placement of a chest
tube via CXR, the outline of the proximal drainage hole
should lie just outside the pleural space
b. when evacuating chronic large pulmonary effusions,
to avoid re-expansion pulmonary edema do not collect
greater than 1.5L within a 30 minute period
c. when considering the removal of a chest tube
initially placed for a pneumothorax; the patient must
be clinically stable, bubbling must have ceased in the
air-leak meter, and the lung must be re-expanded on CXR
d. in order to remove a chest tube initially placed for
pleural fluid drainage; there must be <200cc fluid
draining in the last 24 hours and the fluid must be
serous
Credits
Congratulations! You have now completed the Tube
Thoracostomy Module.
Credits
 This module was written and developed by
Nicole Rocca for the Queen's University
Faculty of Health Sciences Patient Simulation
Lab.
 Contributors: Dr. Chris Parker and Dr. Bob
McGraw
 The module was created using exe :eLearning
XHTML editor with support from Amy Allcock and
the Queen's University School of Medicine
MedTech Unit.
License
This module is licensed under the Creative Commons
Attribution Non-Commercial No Derivatives license. The
module may be redistributed and used provided that
credit is given to the author and it is used for noncommercial purposes only. The contents of this
presentation cannot be changed or used individually.
For more information on the Creative Commons license
model and the specific terms of this license, please
visit creativecommons.ca.
References
1. Kirsch TD, Mulligan JP: Tube Thoracostomy. In
Roberts JR, Hedges JR, et al (eds): Clinical
Procedures in Emergency Medicine, 4th ed.
Pennsylvania, Elsevier, 2004, p 187-209.
2. Dev SP, Bartolomeu N Jr, Simone C, Chien V. Videos
In Clinical Medicine: Chest-Tube Insertion N Engl J
Med. 2007;357:e15.
3. The content of this module was based, in part, on a
learning guide developed by the Nursing Education
Service at Kingston General Hospital.