What are the steps for inserting a chest tube?

Step-by-Step Chest Tube Insertion Procedure

Small-bore chest tubes (8-12 FG) should be used whenever possible to minimize patient discomfort, as there is no evidence that large bore chest drains confer any advantage. 1

Preparation

• Gather all necessary equipment: sterile gloves, gown, chest tube of appropriate size, sterile towels, betadine or chlorhexidine for skin cleansing, local anesthetic, suture material, chest drainage system 1
• Position the patient appropriately:
  • For cooperative patients under local anesthesia: slightly rotated with arm on affected side behind head to expose axillary area 1
  • Alternative positions: upright leaning over a table with a pillow, or lateral decubitus position 1
• Use sterile technique throughout the procedure to avoid wound site infection or secondary empyema 1
• Clean a large area of skin with betadine or chlorhexidine 1

Insertion Procedure

1. Identify insertion site: Typically in the "safe triangle" - bordered by anterior border of latissimus dorsi, lateral border of pectoralis major, and a line horizontal to the nipple 1

2. Administer local anesthesia: Inject local anesthetic at the insertion site and down to the pleura 1

3. Make incision: Create a small incision at the predetermined site, large enough to accommodate the chest tube 1

4. Insert chest tube:

   • For small-bore tubes: Use the Seldinger technique with guidewire 2
   • For larger tubes: Use blunt dissection technique 2
   • NEVER use substantial force or a trocar during insertion as this risks sudden chest penetration and damage to intrathoracic structures 1

5. Direct the tube:

   • For pneumothorax: Direct the tube apically (above the aortic arch) 3
   • For fluid (hemothorax, effusion): Direct the tube basally (toward the diaphragm) 3

6. Secure the tube:

   • Close the incision with a non-absorbable suture around the chest tube 1
   • Apply a stay suture through the skin and criss-cross up the drain (ensure it's not too tight) 1
   • Alternative: Use special dressings/fixation devices to hold the tube in place 1
   • Apply sterile dressing around the insertion site 1

7. Connect to drainage system:

   • Connect the tube to an underwater seal, electronic system, or vacuum chest drainage system 2
   • Ensure all connections are secure 2

8. Confirm placement:

   • Obtain a chest radiograph to confirm proper tube position and to ensure a pneumothorax has not developed 1
   • Look for equal bilateral chest wall expansion with ventilation 1
   • Note: Auscultation may be difficult and risks contamination in certain situations (e.g., COVID-19) 1

Post-Insertion Management

• Record the depth of tube insertion prominently in the patient's chart 1
• Never clamp a bubbling chest tube as this may convert a simple pneumothorax into a tension pneumothorax 1
• Monitor for complications such as pain, drain blockage, accidental dislodgment, organ injury, hemothorax, infections, and re-expansion pulmonary edema 2
• Consider inserting a nasogastric tube after chest tube placement if the patient requires mechanical ventilation 1

Common Pitfalls and How to Avoid Them

• Using excessive force: Always insert the tube gently to avoid damage to intrathoracic structures 1
• Improper positioning: Use imaging guidance (ultrasound or CT) when available to ensure proper placement 2
• Inadequate securing: Ensure the tube is well-secured to prevent accidental dislodgement 1
• Improper drainage system setup: Verify all connections are secure and the drainage system is functioning properly 2
• Failure to obtain post-procedure imaging: Always get a chest radiograph after insertion to confirm proper placement 1