What is the proper procedure for inserting a chest tube?

Proper Procedure for Chest Tube Insertion

The proper procedure for chest tube insertion involves using ultrasound guidance to mark the optimal insertion site, followed by the Seldinger technique for small-bore catheters (10-14F) or blunt dissection for larger tubes, with strict adherence to the 'safe triangle' anatomical landmarks to minimize complications. 1

Indications and Patient Selection

• Primary indications:

  • Pneumothorax (especially large secondary pneumothoraces >2 cm)
  • Pleural effusions (symptomatic, malignant, or recurrent)
  • Hemothorax
  • Empyema/pleural infection (frank pus, pH <7.2)
  • Loculated pleural collections 2, 1

• Contraindications:

  • Coagulopathy (relative)
  • Adhesions between chest wall and lung
  • Skin infection at insertion site

Equipment Required

• Sterile gloves, gown, mask, and cap
• Sterile drapes
• Antiseptic solution
• Local anesthetic (1% lidocaine)
• Syringes and needles
• Scalpel
• Chest tube of appropriate size:
  • Small-bore (10-14F) for most pleural effusions and pneumothoraces
  • Larger tubes for hemothorax or large air leaks 1, 3
• Underwater seal drainage system or electronic drainage device
• Suture material (usually 0 or 1-0 silk)
• Sterile dressings

Procedural Steps

1. Preparation

• Position patient appropriately (usually semi-recumbent at 45° or lateral decubitus)
• Identify and mark the "safe triangle" bordered by:
  • Lateral edge of pectoralis major muscle
  • Anterior border of latissimus dorsi
  • Line superior to the horizontal level of the nipple 1
• Use ultrasound to confirm optimal insertion site and absence of adhesions
• Perform time-out and obtain informed consent
• Administer appropriate analgesia

2. Insertion Technique

For Small-Bore Tubes (Seldinger Technique):

1. Prepare skin with antiseptic solution and drape
2. Infiltrate local anesthetic from skin to pleura
3. Make a small skin incision (~1 cm)
4. Insert finder needle with syringe, aspirating until air or fluid is obtained
5. Pass guidewire through needle
6. Remove needle, leaving guidewire in place
7. Dilate tract over guidewire
8. Pass chest tube over guidewire
9. Remove guidewire, leaving tube in place 1, 3

For Larger Tubes (Blunt Dissection):

1. Prepare skin with antiseptic solution and drape
2. Infiltrate local anesthetic from skin to pleura
3. Make a 2-3 cm incision along the intercostal space
4. Bluntly dissect through subcutaneous tissues and intercostal muscles
5. Puncture pleura with blunt instrument
6. Insert finger to confirm entry into pleural space and absence of adhesions
7. Guide chest tube into pleural space using a curved clamp
8. Direct tube posteriorly and superiorly for air, or posteriorly and inferiorly for fluid 2, 1

3. Securing the Tube

1. Connect tube to underwater seal drainage system
2. Secure tube with suture (mattress or purse-string)
3. Apply occlusive dressing
4. Confirm tube position with chest X-ray 1

Post-Procedure Management

• Keep drainage system below chest level
• Monitor for:
  • Air leak (bubbling in water seal chamber)
  • Drainage amount and characteristics
  • Vital signs and respiratory status
• For large effusions, consider limiting initial drainage to 1-1.5L to prevent re-expansion pulmonary edema 1
• Never clamp a bubbling chest tube 2
• Remove tube when:
  • No air leak for 24 hours
  • Drainage <300 mL/day
  • Clinical and radiographic improvement 1

Potential Complications

• Immediate:

  • Organ injury (lung, heart, liver, spleen)
  • Intercostal vessel injury/hemothorax
  • Pain
  • Subcutaneous emphysema

• Delayed:

  • Infection
  • Tube blockage
  • Accidental dislodgment
  • Re-expansion pulmonary edema 1, 3

Key Safety Points

1. Always use imaging guidance (ultrasound or CT) for tube placement
2. Never use trocar technique due to risk of organ injury
3. Follow the anatomical landmarks of the "safe triangle"
4. Ensure proper analgesia before and during the procedure
5. Confirm tube position with post-procedure imaging
6. Monitor drainage system and patient status regularly 2, 1

The British Thoracic Society and American Thoracic Society guidelines emphasize that proper training and supervision are essential for safe chest tube insertion, with early involvement of respiratory specialists or thoracic surgeons when complications arise 1.