What is the proper procedure for inserting and managing a chest tube (thoracostomy tube) in a patient?

Chest Tube Insertion and Management

Tube Size Selection

Small-bore chest tubes (8-12 French) should be used whenever possible to minimize patient discomfort, as there is no evidence that large bore drains confer any advantage. 1, 2 Studies demonstrate these smaller catheters are as effective as larger tubes while being less traumatic to insert and more comfortable for patients. 1

• For most pneumothoraces and pleural effusions, use 8-14 French catheters 1, 2
• Reserve 16-22 French tubes for clinically unstable patients or anticipated large air leaks 1
• Use 24-28 French tubes only when bronchopleural fistula with massive air leak is anticipated or positive-pressure ventilation is required 1

Pre-Insertion Preparation

Gather all necessary equipment before beginning: sterile gloves, gown, chest tube of appropriate size, sterile towels, betadine or chlorhexidine, local anesthetic, suture material, and chest drainage system. 2

Patient Positioning

• Cooperative patients under local anesthesia: slightly rotated with arm on affected side behind head to expose axillary area 2
• Alternative positions: upright leaning over table with pillow, or lateral decubitus 2

Sterile Technique

• Use sterile gloves, gown, equipment and sterile towels after effective skin cleansing 1
• Clean a large area of skin with betadine or chlorhexidine 1, 2
• This is essential to avoid wound site infection or secondary empyema 1

Insertion Technique

Site Selection

• Identify the "safe triangle" bordered by anterior border of latissimus dorsi, lateral border of pectoralis major, and a line horizontal to the nipple 2

Critical Safety Points

Never use substantial force or a trocar during insertion, as this risks sudden chest penetration and damage to intrathoracic structures including liver and spleen. 1, 2 Many complications with damage to essential intrathoracic structures have been described with trocar use, so these should never be used. 1

Insertion Steps

• Administer local anesthesia at insertion site down to the pleura 2
• Make small incision large enough to accommodate the chest tube 2
• For small-bore catheters, use Seldinger technique with dilators rather than blunt dissection 1
• Insert tube gently without excessive force 1, 2

Securing the Tube

• Close incision with non-absorbable suture to narrow the linear incision around the drain edge 1
• Apply stay suture through skin and criss-cross up the drain, ensuring it's not too tight to occlude a soft drain 1, 2
• Special dressings/fixation devices are available to hold small catheters in place and reduce kinking 1
• Apply transparent adhesive dressing to allow inspection of drain site 1
• Avoid large amounts of tape and padding that may restrict chest wall movement 1

Post-Insertion Confirmation

A chest radiograph must be performed after insertion to confirm proper tube position and ensure a pneumothorax has not developed. 1, 2 An effectively functioning drain should not be repositioned solely because of its radiographic appearance. 1

• Record the depth of tube insertion prominently in the patient's chart 2
• Look for equal bilateral chest wall expansion with ventilation 2

Drainage System Management

All chest tubes must be connected to a unidirectional flow drainage system (underwater seal bottle) kept below the patient's chest level at all times. 1

Initial Drainage Strategy

• Water seal device can be used without suction initially 1
• Apply suction if lung fails to reexpand with water seal drainage 1
• Alternatively, suction may be applied immediately after placement 1
• Small-bore catheters may be attached to Heimlich valve for reliable, stable patients 1

Critical Safety Rule

Never clamp a bubbling chest tube, as this may convert a simple pneumothorax into a tension pneumothorax. 2

Ongoing Management

Monitoring for Obstruction

• If chest tube becomes blocked or drainage ceases, flush with 20-50 ml normal saline to ensure patency 1
• If poor drainage persists, perform chest radiograph or CT scan to check drain position 1
• Look for kinks at the skin with smaller drains, which can be repositioned and redressed 1
• If permanently blocked, remove and insert new tube if indicated 1

Imaging for Failed Drainage

• Contrast-enhanced CT scanning is the most useful modality for patients failing chest tube drainage to identify locules and ensure accurate placement 1
• Both ultrasound and chest radiography may also be useful 1

Tube Removal

Chest tubes should be removed in a staged manner to ensure air leak has resolved. 1

• First stage: chest radiograph demonstrates complete pneumothorax resolution and no clinical evidence of ongoing air leak 1
• Discontinue any suction applied to the chest tube 1
• 53% of expert panel members would never clamp a chest tube before removal 1

Special Considerations for Pleural Infection

Fibrinolytic Therapy

• Intrapleural fibrinolytic drugs (streptokinase 250,000 IU twice daily for 3 days or urokinase 100,000 IU once daily for 3 days) improve radiological outcome in pleural infections 1
• Patients receiving intrapleural streptokinase should be given exposure card and receive urokinase or TPA for subsequent indications 1
• Most adverse events are immunological and occur with streptokinase 1

Common Pitfalls and Prevention

• Using excessive force: Always insert gently to avoid intrathoracic structure damage 1, 2
• Inadequate securing: Ensure tube is well-secured to prevent accidental dislodgement 1, 2
• Failure to obtain post-procedure imaging: Always get chest radiograph after insertion 1, 2
• Trocar use: Never use trocars due to high complication rates 1
• Clamping bubbling tubes: This can create tension pneumothorax 2
• Inadequate skin preparation: Clean large area to prevent infection 1, 2