n engl j med 357;15 www.nejm.org october 11, 2007 e15
videos in clinical medicine
The new engl and jour nal of medicine
Chest-Tube Insertion
Shelly P. Dev, M.D., Bartolomeu Nascimiento, Jr., M.D.,
Carmine Simone, M.D., and Vincent Chien, M.D.
FromtheDepartmentofCriticalCareMedicine,
Sunnybrook Health Sciences Centre,
University of Toronto, Toronto. Address
reprint requests to Dr. Dev at the Department
of Critical Care, Sunnybrook Health
Sciences Centre, 2075 Bayview Ave., Office
D­112, Toronto, ON M4N 3M5, Canada,
or shelly.dev@sunnybrook.ca.
N Engl J Med 2007;357:e15.
Copyright  2007 Massachusetts Medical Society.
Indications
Insertion of a chest tube is indicated in either emergency or nonemergency situations.
Specific indications are listed in Table 1.1-3
Contraindications
Published guidelines state that there are no absolute contraindications for drainage
by means of a chest tube1 except when a lung is completely adherent to the chest
wall throughout the hemithorax.2 Relative contraindications include a risk of bleeding
in patients taking anticoagulant medication or in patients with a predisposition
to bleeding or abnormal clotting profiles. Whenever possible, coagulopathies and
platelet defects should be corrected with the infusion of blood products, such as
fresh frozen plasma and platelets.
Equipment
Most hospitals have presterilized, packaged chest-tube­insertion trays. The key components
of the tray are a scalpel with size 11 blade; several dissecting instruments,
such as curved Kelly clamps or artery forceps; a 10-ml syringe and a 20-ml syringe;
one small-gauge needle (size 25) and one larger-gauge needle for deeper anesthetic
infiltration (size 18­21); a needle driver; scissors; one packet of strong, nonabsorbable,
curved sutures of size 1.0 or larger, made from silk or nylon4; and a chest tube
of appropriate size (see below). A commercially available pleural drainage system,
such as the Pleur-evac (Teleflex Medical), should also be ready for connection after
the chest tube is inserted.
Table 1. Indications for Chest-Tube Insertion.
Emergency
Pneumothorax
In all patients on mechanical ventilation
When pneumothorax is large
In a clinically unstable patient
For tension pneumothorax after needle decompression
When pneumothorax is recurrent or persistent
When pneumothorax is secondary to chest trauma
When pneumothorax is iatrogenic, if large and clinically significant
Hemopneumothorax
Esophageal rupture with gastric leak into pleural space
Nonemergency
Malignant pleural effusion
Treatment with sclerosing agents or pleurodesis
Recurrent pleural effusion
Parapneumonic effusion or empyema
Chylothorax
Postoperative care (e.g., after coronary bypass, thoracotomy, or lobectomy)
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Grasp the proximal free end of the chest tube with a clamp or forceps. Using another
clamp or forceps, grasp the distal tip of the tube to prepare it for insertion.4
Chest-Tube Size
The size of the chest tube that is needed depends on the indication for the insertion
of a chest tube. Table 2 provides a summary of size recommendations based on
indication.5-11
Preparation
If time permits, explain the procedure to the patient or next of kin and obtain written
consent; this may not be possible when the need for chest-tube insertion is urgent.
Position the patient in either a supine or a semirecumbent position. Maximally
abduct the ipsilateral arm or place it behind the patient's head. The area for insertion
is approximated by the fourth to fifth intercostal space in the anterior axillary
line at the horizontal level of the nipple. This area corresponds to the anterior
border of the latissimus dorsi, the lateral border of the pectoralis major muscle,
the apex just below the axilla, and a line above the horizontal level of the nippleoften
referred to as the "triangle of safety."2 You can isolate this area by palpating
the ipsilateral clavicle, then working downward along the ribcage, counting down
the rib spaces. Once the fourth to fifth intercostal space is felt, move your hand
laterally toward the anterior axillary line (Fig. 1). This is the area for incision; the
actual insertion site should be one intercostal space above the chest-tube incision
site. Mark the spot for incision on the skin with a pen or the back of a needle.
Use full barrier precautions (wash your hands and wear a sterile gown and
gloves, protective eyewear, and a face mask). Create a large, sterile field on the patient's
skin, using sterile gauze and 2% chlorhexidine solution. Drape the patient,
exposing only the marked area. Using a 1% or 2% lidocaine solution and a 25-gauge
needle, create a wheal of anesthetic in the cutaneous tissue at the marked spot. Draw
up more lidocaine solution in a 20-ml syringe. Using a 21-gauge needle, anesthetize
the deeper subcutaneous tissues and intercostal muscles. Locate the rib lying below
the intercostal space where the tube will be inserted, and continue to anesthetize
the periosteal surface. Ten to 20 ml of lidocaine solution may be used to
ensure optimal analgesia.1 While anesthetizing the rib, find the superior aspect
of the rib and use this to bevel or "march" the needle on top of it. Using continued
negative suction as the needle advances, with the needle beveled on top of the rib,
confirm entry into the pleural space when a flash of pleural fluid enters the chamThe
new england journal of medicine
n engl j med 357;15 www.nejm.org october 11, 2007
Figure 1. Locating Landmarks.
Table 2. Sizing of Chest Tubes on the Basis of Indication.
Indication for Chest Tube Recommended Size of Chest Tube
Pneumothorax
Large pneumothorax in patient in stable condition 16­French to 22­French
14­French or smaller (insert by Seldinger method)*
Large pneumothorax in patient in unstable condition
Patient receiving mechanical ventilation
Secondary pneumothorax
24­French to 28­French
Pleural collections
Malignant pleural effusion
Transudative effusion
Consider smaller­bore, 8­French to 16­French first*
If ineffective, try larger­bore (22­French or larger)
Parapneumonic effusion
Empyema
No firm recommendations
20­French or larger may be tried
* The Seldinger method of chest­tube insertion is performed with the use of 14­French or smaller chest drains usually under ultrasound guidance
either at the bedside or in a radiology suite. This method is not covered in this review.
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ber of the syringe. If a pneumothorax is being evacuated, the syringe may only fill
with air. Stop advancing the needle and inject any remaining lidocaine to fully
anesthetize the parietal pleura. Withdraw the needle and syringe completely.
Incision and Dissection
An incision 1.5 to 2.0 cm in length should be made parallel to the rib. Use the
Kelly clamp or artery forceps to cut through the subcutaneous layers and intercostal
muscles (Fig. 2). The path should traverse diagonally up toward the next superior
intercostal space. Once you have dissected through the subcutaneous tissues,
find the surface of the rib lying below this space with the dissecting instrument.
Then slide the instrument straight up, until you find the top edge of the rib. Use
this to bevel or balance the dissecting instrument as you dissect the intercostal muscles
(Fig. 3). Once you reach the parietal pleura, gently push the dissecting instrument
through it. You may also digitally penetrate the pleura to avoid puncturing
adjacent lung tissue,3,4 using your index finger to explore the tract. Once your finger
enters the pleura, withdraw the Kelly clamp. Use your finger to palpate within
the pleural layer and ensure that the lung falls away from the pleura.1 If it does
not, this may indicate the presence of an adhesion, so tube insertion may be difficult.
(Trocar insertion, considered dangerous, is no longer advised.4)
Tube Insertion
Once the distal tip of the tube has passed through the incision, unclamp the Kelly
clamps or forceps and advance the tube manually. Aim the tube apically for evacuation
of a pneumothorax and basally for evacuation of any fluid.1-3
Securing the Tube
Mattress or interrupted sutures should be used on both sides of the incision to close
the ends. Use the loose ends of the sutures to wrap around the tube and tie them
off, anchoring the tube to the chest wall.1 Tape the tube to the side of the patient
and wrap a petroleum-based gauze dressing around the tube. Cover this gauze with
several pieces of regular sterile gauze, and secure the site with multiple pressure
dressings.
Purse-string sutures are not recommended owing to poor cosmetic results and
increased risk of skin necrosis; the seal they provide does not prevent air leaks.3
Connect the distal end of the chest tube to a sterile pleural drainage system,
such as the commercially available Pleur-evac. Once the tube is connected, unclamp
the distal end; if there is a pneumothorax, bubbling may be seen. If there
is a large pleural effusion, it will begin collecting. Do not reclamp the chest tube,
once released, unless the pleural drainage system is being changed. Reclamping the
tube may lead to the redevelopment of a pneumothorax and may create a tension
pneumothorax.
Chest Radiograph Confirmation
Once you have secured the chest tube, obtain an anterior-posterior chest radiograph
to confirm placement, which can be done by identifying the radio-opaque
line along the tube. If the proximal drainage hole is outside the pleural space,
drainage may be ineffective and an air leak may result. In this circumstance, the
tube should be removed and a new chest tube inserted.
Complications
The most important complications associated with chest-tube insertion1-3,9 include
bleeding and hemothorax due to intercostal artery perforation, perforation of visceral
organs (lung, heart, diaphragm, or intraabdominal organs), perforation of machest-tube
insertion
n engl j med 357;15 www.nejm.org october 11, 2007
Figure 2. Dissection.
Figure 3. Positioning the Dissection
Instrument.
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jor vascular structures such as the aorta or subclavian vessels, intercostal neuralgia
due to trauma of neurovascular bundles, subcutaneous emphysema, reexpansion pulmonary
edema, infection of the drainage site, pneumonia, and empyema. There may
be technical problems such as intermittent tube blockage from clotted blood, pus,
or debris, or incorrect positioning of the tube, which causes ineffective drainage.
Timing of Chest-Tube Removal
The timing of chest-tube removal depends on the indication for insertion of the
chest tube.
For a pneumothorax, bubbling must have ceased and the lung must be fully
expanded on chest radiograph before the tube can be removed. If suction is being
used to evacuate a pneumothorax, most physicians will use a trial of underwater
seal to ensure that the lung stays expanded without suction. Practice differs greatly
among physicians with regard to duration of observation after air leak cessation
and before removal of the tube and whether or not to clamp the tube before removal
to rule out a persistent air leak.11 On the basis of available data, most physicians
would obtain a chest radiograph 12 to 24 hours after the last observed
evidence of an air leak to ensure that the lung stays fully expanded before tube
removal. Because opinion and practice are clearly divided on the need for clamping
the drain before tube removal, no strong recommendation can be made here.
If placement was for any pleural fluid drainage, once the drainage volume is less
than 200 ml in a 24-hour period,3,5 the fluid is serous, the lung has re-expanded on
the chest film, and the patient's clinical status has improved, the chest tube may
be removed.
If the patient's condition fails to improve after chest-tube insertion, a respirologist
or a thoracic surgeon should be consulted for more definitive management,
such as fibrinolytic therapy or surgical decortication.8,9
Technique of Tube Removal
The major concern with removal of a chest tube is the risk of pneumothorax during
removal. Again, physician practice differs with respect to the point in the respiratory
cycle at which the tube is removed: during end-inspiration or end-expiration.
Neither has been shown to be superior in the prevention of pneumothorax.5 When
preparing to remove the tube, two people may need to participate so that one can instruct
the spontaneously breathing patient and pull the tube while the other can quickly
occlude the insertion site. Cut the skin sutures, using sterile technique. Have
additional strong nylon or silk sutures ready in case additional sutures are required
to seal the hole. Sterile petroleum-based and regular gauze should also be ready.
Instruct the spontaneously breathing patient to perform a forced Valsalva maneuver
or to inhale to total lung capacity after a full exhalation. If the patient is being
fully mechanically ventilated, removal should be timed to end-expiration. One operator
can pull the tube out while the other quickly occludes the site with gauze,
adds additional sutures to close the opening, and secures the site with a pressure
dressing. A chest radiograph 12 to 24 hours after removal is recommended1,3; this
should be done sooner if there is clinical suspicion of a residual air leak or a new
pneumothorax.
Caution must be exercised when removing a chest tube from any patient receiving
mechanical ventilation. This is of particular importance for patients with high
oxygen or positive end-expiratory pressure requirements, chronic lung disease, or
any additional reasons for persistent air leaks or recurrent pneumothoraces. In
these cases, highly experienced physicians should supervise the decision to remove
a chest tube.
No potential conflict of interest relevant to this article was reported.
chest-tube insertion
n engl j med 357;15 www.nejm.org october 11, 2007
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Copyright  2007 Massachusetts Medical Society.
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