What are the steps to insert a chest tube?

Chest Tube Insertion Procedure

Pre-Procedure Preparation

Use small-bore chest tubes (8-14F) as first-line for most indications, as they are equally effective as large-bore tubes while causing significantly less patient discomfort and improving mobility. 1, 2

Patient Positioning

• Position cooperative patients under local anesthesia slightly rotated with the arm on the affected side behind the head to expose the axillary area 3, 2
• Alternative positions include upright leaning over an adjacent table with a pillow, or lateral decubitus position 3, 2
• For patients under general anesthesia, position flat on back, rolling the patient if the insertion site is posterior 3

Equipment Assembly

• Gather all equipment before starting: sterile gloves, gown, chest tube (8-12F preferred), sterile towels, betadine or chlorhexidine, local anesthetic (0.25% bupivacaine up to 2 mg/kg or lidocaine up to 3 mg/kg), suture material, and drainage system 3, 2
• Ensure proper lighting, resuscitation equipment, oxygen, and suction are available 3

Site Selection

• Insert small-bore drains at the optimum site identified by chest ultrasound 3
• For large-bore surgical drains, use the "safe triangle" in the mid-axillary line—bordered by the anterior border of latissimus dorsi, lateral border of pectoralis major, and a horizontal line at nipple level 3, 2
• The 4th or 5th intercostal space in the mid- or anterior-axillary line is most appropriate 4

Insertion Technique

Anesthesia and Sterile Preparation

• Use strict sterile technique with sterile gloves, gown, and equipment 3, 1
• Cleanse a large area of skin thoroughly with betadine or chlorhexidine 3, 2
• Infiltrate local anesthetic into the skin to raise a dermal bleb, then deeper into subcutaneous tissue, intercostal muscles, periosteum of the rib, and parietal pleura 3, 2

Tube Insertion

• Never use substantial force or a trocar during insertion—this is critical to avoid sudden chest penetration and damage to intrathoracic structures including liver and spleen 3, 1
• Use the Seldinger technique for small-bore drains (8-14F), which is safer than trocar methods 1, 5
• For larger tubes (>24F), use blunt dissection technique 5
• Make a small incision at the predetermined site, just large enough to accommodate the chest tube 2

Securing the Drain

• Close the incision with a non-absorbable suture to narrow the linear incision around the drain 3, 1
• Secure the drain well to prevent dislodgement using a stay suture placed through the skin and criss-crossed up the drain (ensuring it's not too tight to occlude a soft drain) 3, 2
• Alternative securing methods include special dressings/fixation devices, steristrips, or transparent adhesive dressing to allow inspection of the drain site 3, 1
• Avoid large amounts of tape and padding that may restrict chest wall movement 3

Post-Insertion Management

Immediate Confirmation

• Obtain a chest radiograph immediately after insertion to confirm proper tube position and ensure no pneumothorax has developed 3, 2
• An effectively functioning drain should not be repositioned solely based on radiographic appearance 3
• Record the depth of tube insertion prominently in the patient's chart 2

Drainage System Connection

• Connect all chest tubes to a unidirectional flow drainage system (such as underwater seal) that must be kept below the level of the patient's chest at all times 3, 1, 2
• The underwater seal tube should be placed 1-2 cm under water 3
• Options include flutter valves, underwater seal bottles, or vacuum bottles for indwelling pleural catheters 1

Suction Management

• Do not apply suction immediately after insertion 1
• Suction can be added after 48 hours for persistent air leak or failure of pneumothorax to re-expand 1
• If used, apply low-pressure suction at 5-10 cm H₂O via the underwater seal 3
• Appropriately trained nursing staff must supervise chest drain suction 3

Critical Safety Points

What Never to Do

• Never clamp a bubbling chest drain—this may convert a simple pneumothorax into a life-threatening tension pneumothorax 1, 2
• Never use trocars for insertion due to high risk of organ injury 3, 5
• Never reposition an effectively functioning drain based solely on radiographic appearance 3

Monitoring and Troubleshooting

• Respiratory swing in the fluid confirms tube patency and proper pleural position 3
• Continuous bubbling indicates either pyopneumothorax with visceral pleural air leak, or the drain is partly out with holes open to atmosphere 3
• If sudden cessation of drainage occurs, check for obstruction by flushing the drain 1
• Refer patients to respiratory physicians if pneumothorax fails to respond within 48 hours 1