Basic Technique for Chest Tube Placement
Small-bore chest tubes (8-14F) should be inserted using the Seldinger technique in the "safe triangle" under sterile conditions, with proper positioning, local anesthesia, and blunt dissection—never using a trocar or excessive force. 1, 2, 3
Pre-Insertion Preparation
Equipment and Sterile Setup
- Gather all necessary equipment including sterile gloves, gown, chest tube (preferably 8-12F), sterile towels, betadine or chlorhexidine for skin cleansing, local anesthetic, suture material, and chest drainage system 1
- Use strict sterile technique throughout the procedure to prevent wound site infection or secondary empyema 1, 2
- Clean a large area of skin with betadine or chlorhexidine 1
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 1
- Alternative positions include upright leaning over a table with a pillow, or lateral decubitus position 1
Insertion Procedure
Site Selection
- Identify the insertion site in the "safe triangle"—bordered by the anterior border of latissimus dorsi, lateral border of pectoralis major, and a line horizontal to the nipple 1
- The 4th or 5th intercostal space in the mid- or anterior-axillary line is the most appropriate location 4
Anesthesia and Incision
- Administer local anesthesia by injecting at the insertion site and down to the pleura 1
- Make a small incision at the predetermined site, large enough to accommodate the chest tube 1
Insertion Technique
- Use the Seldinger technique for small-bore drains (8-14F), as it is safer than trocar insertion methods 2, 3
- For larger tubes (>24F), use blunt dissection technique 3
- Never use substantial force or a trocar during insertion, as this risks sudden chest penetration and damage to intrathoracic structures including hemothorax, lung lacerations, and injury to organs in the thoracic or abdominal cavity 1, 2, 4
- Insert the tube gently to avoid complications 1
Securing and Post-Insertion Management
Tube Fixation
- Close the incision with a non-absorbable suture around the chest tube 1, 2
- Apply a stay suture through the skin and criss-cross up the drain 1
- Ensure the tube is well-secured to prevent accidental dislodgement using stay sutures, special dressings/fixation devices, or steristrips and transparent adhesive dressing 2
- Apply sterile dressing around the insertion site 1
Drainage System Connection
- Connect all chest tubes to a unidirectional flow drainage system kept below the level of the patient's chest at all times 2
- Options include flutter valves, underwater seal systems, or electronic drainage systems 2, 3
Confirmation of Placement
- Obtain a chest radiograph immediately after insertion to confirm proper tube position and ensure a pneumothorax has not developed 1
- Look for equal bilateral chest wall expansion with ventilation 1
- Record the depth of tube insertion prominently in the patient's chart 1
Critical Safety Points
What Never to Do
- Never clamp a bubbling chest tube, as this may convert a simple pneumothorax into a tension pneumothorax 1, 2
- Never use the trocar technique due to high risk of organ injury 4, 3
- Do not apply suction immediately after tube insertion 2
When to Apply Suction
- Suction can be added after 48 hours for persistent air leak or failure of pneumothorax to re-expand 2
- Patients requiring chest drainage with suction should be managed on specialized units with appropriate medical and nursing expertise 2
Additional Considerations
- Consider inserting a nasogastric tube after chest tube placement if the patient requires mechanical ventilation 1
- Small-bore tubes (8-14F) are as effective as larger tubes for most indications including pneumothorax and pleural effusions, while causing less pain and improving patient mobility 2, 3
- Larger tubes may be necessary for hemothorax, large air leaks exceeding the capacity of smaller tubes, or when small tubes have failed 2