What is the proper technique for inserting a chest tube to treat pneumothorax?

From the Guidelines

Chest tube placement for pneumothorax should be performed by creating a controlled pathway to evacuate air from the pleural space, with suction applied after 48 hours if there is a persistent air leak or failure of the pneumothorax to re-expand, using a high volume, low pressure system at -10 to -20 cm H2O suction 1. The procedure involves positioning the patient in the supine or semi-recumbent position with the arm abducted. After obtaining informed consent, identify the "triangle of safety" bordered by the anterior border of latissimus dorsi, lateral border of pectoralis major, and a horizontal line at the level of the nipple (typically 4th-5th intercostal space, mid-axillary line). Some key points to consider during the procedure include:

• Clean the area with chlorhexidine or povidone-iodine solution and drape to create a sterile field.
• Administer local anesthesia (1-2% lidocaine) to the skin, subcutaneous tissue, periosteum, and pleura.
• Make a 2-3 cm transverse incision along the upper border of the rib to avoid neurovascular structures.
• Use blunt dissection with a curved clamp to create a tract through the intercostal muscles.
• Puncture the pleura with the clamp, then widen the opening.
• Insert the chest tube (typically 24-28 French for pneumothorax) with the tip directed apically for air evacuation, advancing it to the desired depth (approximately 5-15 cm).
• Secure the tube with a suture, apply an occlusive dressing, and connect to an underwater seal drainage system.
• Confirm proper placement with a chest X-ray. It is essential to note that suction should not be applied directly after tube insertion, but can be added after 48 hours for persistent air leak or failure of the pneumothorax to re-expand, as recommended by the BTS guidelines for the management of spontaneous pneumothorax 1. Additionally, the use of high volume, low pressure suction systems is recommended, as they are more effective in draining the pleural space and reducing the risk of complications such as air stealing, hypoxaemia, or perpetuation of persistent air leaks 1. The American College of Chest Physicians Delphi consensus statement also supports the use of chest catheter insertion for unstable patients with large pneumothoraces, and recommends the use of a 16F to 22F standard chest tube or a small-bore catheter, depending on the degree of clinical instability 1. However, the BTS guidelines provide more specific recommendations for the management of spontaneous pneumothorax, including the use of intercostal tube drainage and the application of suction 1. Therefore, the most recent and highest quality study, which is the BTS guidelines for the management of spontaneous pneumothorax 1, should be prioritized when making a definitive recommendation for the proper technique for inserting a chest tube to treat pneumothorax.

From the Research

Proper Technique for Inserting a Chest Tube

• The insertion of a chest tube should be guided by imaging, either bedside ultrasonography or computed tomography 2.
• The trocar technique should be avoided, and instead, blunt dissection (for tubes >24F) or the Seldinger technique should be used 2.
• Small-bore chest tubes (≤14F) are generally recommended as the first-line therapy for spontaneous pneumothorax in non-ventilated patients and pleural effusions in general 2.
• Large-bore chest drains may be useful for very large air leaks, as well as post-ineffective trial with small-bore drains 2.

Considerations for Chest Tube Insertion

• Risk factors for re-expansion pulmonary edema, a rare and potentially life-threatening complication, include rapid re-expansion of the lung, young patient age, and a large pneumothorax persisting longer than 24 hours 3.
• If these risk factors are present, the chest tube should be inserted without primary suction to allow the lung to re-expand more slowly 3.
• For unstable patients with chest trauma, a large-bore drain (24 French or larger) should be used, while stable patients can receive a small-bore chest tube (e.g. 14 French) 4.

Management and Complications of Chest Tubes

• Chest tubes should be connected to a drainage system device, such as a flutter valve, underwater seal, or electronic systems 2.
• The optimal timing for tube removal is still a matter of controversy, but digital drainage systems can facilitate informed decision-making 2.
• Complications of chest tube insertion can include organ injury, hemothorax, infections, and re-expansion pulmonary edema 2, 3, 5.
• Incorrect positioning of the tube is a common complication, but can usually only be reliably detected or ruled out with a CT scan 4.