Chest Tube Reinsertion Site Selection
Insert the new chest tube at a different intercostal space rather than using the same site as the previous tube. This approach minimizes complications from scarring, infection risk, and tissue trauma at the original insertion site.
Rationale for Different Site Selection
Primary Considerations
Avoid compromised tissue: The previous insertion site has disrupted tissue planes, potential scarring, and altered anatomy that increases risk of malposition, bleeding, and infection 1, 2.
Infection prevention: Sterile technique is essential during insertion, and re-using a site that may harbor colonized tissue or have compromised skin integrity increases pleural infection risk (which occurs in 1-6% of cases) 1.
Optimize drainage position: A fresh site allows you to select the optimal location based on current imaging (chest ultrasound or CT) showing where fluid or air has accumulated, rather than being constrained by previous anatomy 1, 3.
Recommended Approach for New Tube Placement
Site Selection Algorithm
Use imaging guidance: Chest ultrasound should guide the optimal insertion site for the current clinical situation, which may differ from the original indication 1.
Standard anatomical landmarks: Place the tube in the 4th-6th intercostal space in the mid- or anterior-axillary line, unless imaging suggests a different optimal location 2, 4.
Avoid the same intercostal space: Choose an adjacent space (one rib space above or below) if the general area is still appropriate, or select an entirely different location based on current pathology 2, 4.
Technical Considerations
Small bore drains preferred: Use 10-14F tubes initially, as they are as effective as large bore tubes (20-24F) with better patient comfort and shorter hospital stays 1.
Never use trocar insertion: Closed insertion with a trocar significantly increases injury risk to vessels, organs, and lung parenchyma 2, 4.
Confirm position immediately: Verify tube placement with chest radiography after insertion to rule out malposition 3.
When Multiple Tubes Are Needed
Concurrent Tube Placement
Consider a second tube rather than repositioning: If a residual collection persists despite a patent first tube, place a second chest tube at a different site rather than manipulating or repositioning the existing tube 3.
Minimize manipulation: Manipulation of chest drainage systems increases infection risk and should be minimized 1.
Critical Safety Points
Pitfalls to Avoid
Never clamp a bubbling chest tube: This can convert a simple pneumothorax into life-threatening tension pneumothorax 1, 3, 5.
Avoid excessive force: Never use substantial force during insertion, as this causes organ injury and potential pulmonary artery damage 3.
Watch for diaphragm position: The diaphragm can cross into or above the 5th intercostal space in up to 45% of patients (especially on the right side), making ultrasound guidance valuable 6.