CHEST TUBE

Placement and Management

DHMG Trauma/ACS Education

 Chest thoracostomy is an invasive
procedure which involves placement of
a plastic tube into the thoracic cavity
with the intention of evacuating air,
blood or other fluid from the pleural
space, allowing for full expansion of
the lung. There are four different
approaches to this procedure:
1. Blunt dissection at the bedside
2. Pigtail placement at the bedside
3. Interventional Radiology placement
under imaging guidance
4. Surgically placed chest tubes during
an open procedure.
DIAGNOSTICS:
CHEST XRAY
CHEST CT
Diagnostics:
Bedside Ultrasound
 1. Pneumothorax (if large, progressive, or if
the patient is symptomatic)
2. Tension pneumothorax
3. Penetrating chest trauma
4. Traumatic cardiac arrest to ‘vent the chest’
5. Hemothorax
Indications 6. Chylothorax (lymphatic fluid)
7. Empyema (purulent material)
8. Pleural effusions
9. Prevention of hydrothorax after
cardiothoracic surgery
10. Bronchopleural fistula
Relative Contraindications
Coagulopathy
*If patient is going to IR for pigtail chest tube placement, prophylactic Lovenox and/or Heparin must be held
 1. 1% Lidocaine with Epinephrine, 10 ml syringe with
25 gauge needle
2. ChloraPrep
3. Sterile gloves, masks, and hat
4. Sterile tray to include: 4 x 4 gauze, Drapes,
hemostat, Kelly clamps, Scissors, Needle driver
5. Sterile thoracostomy tube
Supplies 6. Scalpel

needed 7. 2-0 silk suture

8. Petroleum-soaked gauze
9. Chest atrium: Sahara or Oasis
10. Chest tube

**Consider need for procedural sedation before

starting; this requires additional staff and supplies
 WHICH SIZE
CHEST TUBE?

Pediatric Chest Tube Size=

4 x ETT diameter
BLUNT CHEST TUBE PLACEMENT
-Quick access to the thoracic cavity
-More invasive/painful
-Done without imaging guidance
Blunt Chest Tube Procedure
1. Evaluate anatomy and select site (4th-5th intercostal space anterior-axillary line). Position the patient with ipsilateral arm out
of the way.

2. Cleanse and prepare site with ChloraPrep and place sterile towels around site.

3. Consider need for procedural sedation. Infiltrate skin with 1% Lidocaine starting with a wheal at the skin and down to the rib
along the anticipated tract.

4. Make a 2 to 3 cm transverse incision through the skin and the subcutaneous tissues overlying the interspace.

5. Extend the incision by blunt dissection with a Kelly clamp through the fascia toward the superior aspect of the rib above.
After the superior border of the rib is reached, close the Kelly clamp, and push it through the parietal pleura with steady, firm,
and even pressure. Open the clamp widely to spread the intercostal muscle and remove the clamp. A "rush of air" or "rush of
blood" is typically noted after entry and the initial spread.

6. Insert an index finger and sweep to verify that the pleural space, not the potential space between the pleura and chest wall,
has been entered.

7. Grasp the chest tube (24-32fr) so that the tip of the tube protrudes beyond the jaws of the clamp and advance it through the hole
into the pleural space using your finger as a guide. Direct the tip of the tube posteriorly for fluid drainage or anteriorly and
superiorly for pneumothorax evacuation. Advance it until the last side hole is 2.5 to 5 cm (1 to 2 inches) inside the chest wall.

8. Attach the tube to the previously assembled atrium, place to suction and suture the tube in place with 2-0 silk.

9. Obtain post-placement chest xray to confirm correct positioning.

Bedside Pigtail Chest Tube
The pigtail catheter is a percutaneous chest tube used for
drainage of pleural effusions or pneumothorax. It is less
invasive and can be done without imaging guidance at the
bedside. It can be a reliable alternative to the standard chest
tube in a non-emergent setting. The catheter is placed using
the Seldinger technique.

The Wayne pigtail catheter package includes the following:

-Needle with syringe
-J-tip guide wire that is designed to decrease the potential for lung injury.
-scalpel
-plastic dilator
-14 French pigtail catheter that is 29 cm long and has an adaptor at the end
for connecting to the drainage system. The pigtail has six holes along the
shaft that curl to the inside when the catheter is in place.
Pigtail Chest Tube Procedure
1. Evaluate anatomy and select site (5th intercostal space AAL or 2nd intercostal space MCL). Position the patient with ipsilateral arm out of the way.

2. Cleanse and prepare site with ChloraPrep and place sterile towels around site.

3. Consider need for procedural sedation. Infiltrate skin with 1% Lidocaine starting with a wheal at the skin and down to the rib along the anticipated tract.

4. Insert the 18 gauge needle with syringe attached into the skin and aspirate for fluid or air to verify placement.

5. Remove the syringe; care must be taken to occlude the lumen when the syringe is removed to prevent air embolus.

6. Straighten the J tip of the guide wire and insert into the needle catheter. Advance guide wire about 2-3 cm beyond the tip of the needle.

7. With a firm grip, hold the guide wire in place as the needle is withdrawn.

8. Place the cutting edge of the scalpel away from the wire and make a small cut

9. Advance dilator over the guide wire to dilate the subcutaneous tissues. Gently roll the dilator between thumb and forefinger using
clockwise/counterclockwise motions to advance the dilator. Maintain a firm grasp on the guide wire during this maneuver.

9. Remove dilator while maintaining the guide wire in stable position.

10. Straighten the pigtail catheter tip and insert over the guide wire using the same twisting motion. Advance until all holes are in the chest plus 1- 2cm further.

11. Slowly withdraw the guide wire while holding the pigtail firmly in place. As the guide wire is withdrawn the pigtail will curl against the chest wall.

12. Place chest tube to suction and secure to the skin with silk suture.

13. Obtain CXR to confirm correct placement.

 ◦ Daily Chest Xray (portable)

Orders to ◦ Chest Tube power set with instructions to

continuous -20 cmH2O suction
place on a ◦ Nursing communication order:

patient with ◦ Never clamp the chest tube

◦ call if output >200cc/hr
Chest Tube ◦ Call if chest tube displaced

in place: ◦ RT eval/treat
◦ Incentive spirometry
◦ Pain control orders
 Complication Solution
Incorrect Placement
--Subcutaneous, transdiaphragmatic, intrafissure, intrapleural -replace or maneuver tube
intraabdominal

-trace line and replace equipment

Persistent air leak -adjust tube placement; ensure tight seal
-surgical fixation of bronchial/pulmonary injury
Hemorrhage -blood volume replacement and Surgical Exploration
--Greater than 1.5 L on placement or >200cc/hr sustained

Damage to surrounding structures -surgical repair

--Heart, great vessels, lung parenchyma, diaphragm, liver, stomach,

Infection/Empyema -antibiotics and continued drainage of empyema

-reposition/replace chest tube

Recurrent or persistent pneumothorax -return to suction if on water seal
-consider VATS/Thoracic consult
Re-expansion Pulmonary Edema -ventilatory support

Tube obstruction -CXR to eval if kinked or displaced

Daily monitoring of chest tube:
• Assess for tidaling of the chest tube, which is when the fluid/ball in the water seal chamber or along a dependent
portion of the tubing is seen to move back and forth with respiration. This a sign that a patent chest tube is affected by
the negative pressure created by the diaphragm. The absence of fluid oscillation can be an indication of tube
obstruction (clots, kinked tube position, etc) OR can be normal with resolution of the pneumothorax.
• Follow with daily chest XR.
• Discuss if chest tube remains to suction for the day or will be placed to water seal.
• Chest tube daily fluid output.
• Palpate for more subcutaneous emphysema around insertion site.
• Monitor for air leak by looking at the fluid chamber for bubbling. Air leak is expected initially as the pneumothorax is
decompressing. Continuous air leak, however, indicates a disruption of the seal somewhere in the closed system. This
could be from any of the following:
• atrium/tubing
• inadequate dressing/seal around the tube at the skin
• the chest tube’s sentinel hole may have migrated out of the chest wall
• Intrathoracic source; direct injury to the bronchus/lung parenchyma
THE ORIGINAL THREE BOTTLE SYSTEM
Air Leak
Air leak is bubbling seen within the water seal
chamber. It is expected initially with
decompression of the pneumothorax, but if it
continues or a new air leak begins later in the
course, its source needs to be identified.

Identifying site of air leak:

1. Pinch at insertion site. If continued air leak,
the problem is in the tubing, connection site
or atrium. If bubbling stops, the problem is
with the insertion site, chest tube or
intrathoracic.
2. Continue sequentially down the tube to find
where the bubbling stops. This will isolate
and identify the site of air leak.
 When to discontinue chest tube:
Typical approach on this service:

Suction → Water Seal→ follow up CXR → If stable, remove chest tube and place dressing →6 hour final CXR

Criteria:

❑No longer presence of air leak

❑Fluid output <200ml/24 hours (<2 cc/kg/day)

❑CXR with stable or resolved pneumothorax

❑Patient is clinically improved and symptoms resolving

Discontinuing a Chest Tube
How to Remove a regular chest tube:
1. Prepare dressing with xeroform, gauze and micro foam tape.
2. Cut suture at insertion site.
3. Have patient inhale and hold it while you smoothly/quickly remove chest tube at end-inspiration.
4. Simultaneously place the dressing over site.

How to Remove a pigtail chest tube:

As above, however you must also release the suture causing the pigtail by cutting across the tube prior to removal or
release the locking mechanism.

Discharge Instructions (sample):

-No scuba diving or flying x 1-2 months
-Maintain dressing in place for at least 48 hours.
-Continue using incentive spirometer at home
-Return to ED if worsening chest pain, shortness of breath or hemoptysis
 1. Filosso PL, Guerrera F, Sandri A, Roffinella M, Solidoro P, Ruffini E, Oliaro A. Errors and
Complications in Chest Tube Placement. Thorac Surg Clin. 2017 Feb;27(1):57-67. doi:
10.1016/[Link].2016.08.009. PMID: 27865328.

2. Zeiler J, Idell S, Norwood S, Cook A. Hemothorax: A Review of the Literature. Clin Pulm Med. 2020
Jan;27(1):1-12. doi: 10.1097/CPM.0000000000000343. Epub 2020 Jan 10. PMID: 33437141; PMCID:
PMC7799890.

3. Pich H, Heller AR. Obstruktiver Schock [Obstructive shock]. Anaesthesist. 2015 May;64(5):403-19.
German. doi: 10.1007/s00101-015-0031-9. PMID: 25994928.

4. Zisis C, Tsirgogianni K, Lazaridis G, Lampaki S, Baka S, Mpoukovinas I, Karavasilis V, Kioumis I,

Pitsiou G, Katsikogiannis N, Tsakiridis K, Rapti A, Trakada G, Karapantzos I, Karapantzou C,
Zissimopoulos A, Zarogoulidis K, Zarogoulidis P. Chest drainage systems in use. Ann Transl Med.
2015 Mar;3(3):43.

References
5. Merkle A, Cindass R. Care Of A Chest Tube. [Updated 2021 Oct 9]. In: StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from:
[Link]

6. Bauman ZM, Kulvatunyou N, Joseph B, Gries L, O'Keeffe T, Tang AL, Rhee P. Randomized Clinical
Trial of 14-French (14F) Pigtail Catheters versus 28-32F Chest Tubes in the Management of Patients
with Traumatic Hemothorax and Hemopneumothorax. World J Surg. 2021 Mar;45(3):880-886. doi:
10.1007/s00268-020-05852-0. Epub 2021 Jan 7. PMID: 33415448; PMCID: PMC7790482.

7. American College of Surgeons Committee of Trauma (2018) Advanced trauma life support: student
course manual, 10th edn. American College of Surgeons Committee on Trauma, Chicago

8. Strutt J, Kharbanda A. Pediatric Chest Tubes And Pigtails: An Evidence-Based Approach To The
Management Of Pleural Space Diseases. Pediatr Emerg Med Pract. 2015 Nov;12(11):1-24; quiz 20-1.
Epub 2015 Nov 2. PMID: 26488231.

PowerPoint revised 12/2021 Brittany Thompson PA-C. Final Approval: Dr. Charles Hu 12/2021