Chest Tube Insertion
Colleen Fitzpatrick, MD, and Karen J. Brasel, MD, MPH, FACS
he concept of placing a tube through the ribs into the
T chest cavity to evacuate fluid and air was described in
the days of Hippocrates. After the Korean War, emer-
gency chest tube placement became more common, pre-
sumably because of better methods of anesthesia and
pleural drainage systems. Today, chest tube insertion is
considered a routine bedside procedure and is taught
widely to surgeons and non-surgeons.
Understanding basic anatomy and physiology provides
a foundation for the placement of chest tubes and their
management. As is true of all percutaneous procedures,
identifying and respecting anatomic landmarks is the
mainstay to successful performance of this procedure.
Inability to accurately assess landmarks leads to a lack of
certainty in placement of these tubes. This is especially
true in women and in obese patients. The mechanics of
respiration depend on both the bony and elastic compo-
nents of the chest wall. Inspiration depends on negative
pressure to expand the lung within the moving chest wall.
Normal intrapleural pressure is about ⫺2.5 mm Hg.10
This pressure decreases to ⫺6 mm Hg at the onset of
inspiration. Passive recoil accounts for expiration. When
this balance has been disrupted by a communication con-
necting the outer world with the inner thoracic cavity, the
From the Medical College of Wisconsin, Milwaukee, WI.
Address reprint requests to Dr. John A. Weigelt, Division of Trauma/Critical
Care, 9200 W. Wisconsin, Milwaukee, WI 53226.
© 2003 Elsevier Inc. All rights reserved.
1524-153X/03/0503-0149$30.00/0
doi:10.1016/S1524-153X(03)00036-8
lung cannot fully expand. Intrapleural pressure is below
atmospheric pressure and thus, when the chest cavity is
opened, the lung collapses. Therefore, chest tube place-
ment is a method of restoring the normal relationship
between the lung, pleura, and chest wall to ensure full
lung expansion.
INDICATIONS
Indications for the placement of a chest tube include air
(pneumothorax), blood (hemothorax), or fluid (effusion)
within the thorax. This can be further broken down into
symptomatic and asymptomatic, spontaneous, iatrogenic
and traumatic, small and large. Tension pneumothorax
defines the condition when the amount of pressure in the
chest cavity continues to increase because of the progres-
sive increase in the amount of air. Additional indications
for chest tube placement include penetrating chest
trauma with a combination of hemopneumothorax, com-
plicated or recurrent pleural effusions, chylothorax,
symptomatic malignant effusions, postoperative prophy-
laxis, and bronchopleural fistula.1
Table 1. Relationship Between Inner and Outer Diameters of
Chest Tubes
Outer diameter (French) Inner diameter (mm)
6F 2mm
20F 5mm
40F 11mm
130 Fitzpatrick and Brasel

TECHNIQUE

1 Consent from the patient should be obtained if possible. The patient should be positioned supine with the ipsilateral arm
abducted at approximately a 45-90 degree angle. In general, larger tubes (38F) are used for a hemothorax and smaller tubes (28F)
are used for the treatment of pneumothorax. The relation between the tube’s outer and inner diameter is proportional (Table 1).
Before the patient is prepared and draped, identification of the anatomic landmarks is essential. The angle of the sternum and most
of the ribs will be covered from direct vision once the procedure has begun. Realizing that men and women have different chest wall
anatomy explains why this procedure requires attention to the surface anatomy. The mid-clavicular line extends caudally from the
curvature in the clavicle. The anterior and posterior axillary lines extend caudad from the point where the pectoralis major and
latissimus dorsi meet the chest wall, respectively. The long thoracic nerve and thoracodorsal nerves descend on the chest wall near
the posterior axillary line.
Chest Tube Insertion 131

2 The patient should be in the supine position or slightly rotated to the side opposite the chest tube placement. At this time,
observation of the action of abduction of the arm on the position of both the pectoralis major and the latissimus dorsi should be
noted. Abduction greater than 90° decreases the effective working space for placement of a chest tube. The final landmarks are the
nipple and the xiphoid process. Both have been described as the means of identifying optimal position for superior/ inferior chest
tube placement. (A) Before preparing and draping, the 2nd rib should be palpated at the sternal angle. Count through the 6th rib.
Visualize the relationship of the 4th or 5th intercostal space to the nipple and xiphoid. There is a downward curvature of the ribs. The
diaphragm attaches at the 9th rib laterally and can rise as high as the 4th intercostal space. If the nipple is chosen as the landmark then
moving just lateral to this point coordinates with the 4th or 5th intercostal space. If the xiphoid is used as a landmark and the
examiner follows the curvature of the ribs, even though the xiphoid is lower on the anterior chest wall the same intercostal space
is achieved. If the xiphoid is used as a landmark following directly lateral, it will most often be in a slightly lower position compared
with the nipple. The relationship of the nipple will be distorted in a woman with pendulous breasts and therefore understanding the
anatomic relationship between nipple and xiphoid is essential for an optimal landmark to ensure proper placement. (B)With the
patient in a supine position, the landmarks are identified, and the patient is prepared and draped. (C) Local anesthesia is placed
along the rib space into the intercostal muscles and the pleura. Aspiration before injection is necessary to avoid the intercostal artery
and vein. A 1 to 3 cm horizontal incision is made directly over that rib lying just below the intercostal space where the chest tube
is to be passed.
132
COMPLICATIONS OF INSERTION
Complications include bleeding, damage to adjacent or-
gans or major vessels in the chest, subcutaneous emphy-
sema, local pain and infection, malposition, empyema,
and intercostal nerve damage. The incidence of compli-
cations does not depend on the mechanism of injury. Stab
wounds, gunshot wounds, and blunt trauma all carry a
2% to 3% risk of empyema.2 The incidence of complica-
tions is slightly higher with the use of a trocar. It is also
higher depending on the expertise of the person placing
the tube. In general, surgeons have a lower complication
rate than nonsurgeons, perhaps because they are more
familiar with the anatomic landmarks.3
3 A subcutaneous tunnel is directed up and over the rib. This
subcutaneous tunnel decreases the risk of air leak, empyema,
and recurrent pneumothorax. The neurovascular structures lie
on the undersurface of the rib. With increased age these vessels
become increasingly tortuous and therefore have a higher risk
of being damaged during tube insertion and bleeding may en-
sue. The tunnel should be adequate in size to place one finger
through and palpate the parietal pleura. Spreading the jaws of
the clamp to make it as wide as possible facilitates easy tube
placement. The lung and diaphragm are palpated. If free space
is not felt, any adhesions can be bluntly finger dissected. If they
do not dissect easily the chest tube should not be placed.
Fitzpatrick and Brasel
POST-PROCEDURE MANAGEMENT
4 Once the tube is directed toward the posterior chest it
should be secured to the skin with suture and then taped in
place. Tubing should never have dependent loops where fluid
can collect. The collection system should rest below the level of
the patient. Chest tubes can be placed to water seal or suction
(⫺10 to ⫺20 mm H2O). Nonmechanically ventilated patients
can generate up to ⫺30 mm Hg of pressure with forceful inspi-
ration. Therefore, the choice of placing patients on water seal or
suction must be tailored to the condition of the patient. Large
air leaks may persist despite being placed to water seal or suc-
tion.5 In patients with a large volume of blood loss from the
chest tube, retrieving up to two units of blood is useful by
autotransfusion techniques.
METHOD FOR REMOVAL
General guidelines for removal of chest tubes include: (1)
ensuring patient comfort, (2) preventing recurrent
pnemothorax, and (3) preventing damage to adjacent
structures. To remove a chest tube the patient may need
to rotate slightly to remove the dressing and any sutures
that were placed at the time of insertion. Preparation of
the dressing that will cover the wound should be done
before the removal of the tube. The dressing can be placed
loosely over the chest tube and wound before the tube is
removed. Once the patient is comfortable the instructions
Chest Tube Insertion
that follow should be clear so that the removal is coordi-
nated. Removal at end expiration or end inspiration does
not affect the rate of pneumothorax. Current rates of
recurrent pneumothorax range widely between 2% and
24%. Of these recurrences only 1% to 6% need to have a
chest tube reinserted. The rate of recurrent pneumotho-
rax also does not appear to be affected by a trial of water
seal. Other factors that may play a role in a pneumothorax
following removal include the presence of a tunnel at the
time of insertion, the experience of the person removing
the tube, the age of the patient, or the ventilation status of
the patient. Following removal, the best guideline for
obtaining a chest radiograph is using clinical judgment
since the need for re-inserting a chest tube is low.
REFERENCES
1. Miller KS, Sahn SA: Chest tubes: Indications, technique, manage-
ment and complications. Chest 91:258-264, 1987
133
2. Millikan JS, Moore EE, Steiner E, Aragon GE, Van Way CW III:
Complications of tube thoracostomy for acute trauma. Am J Surg
140:738-741, 1980
3. Etoch SW, Bar-Natan MF, Miller FB, Richardson JD: Tube thora-
costomy: Factors related to complications. Arch Surg 130:521-
525, 1995
4. Bell RL, Ovadia P, Abdullah F, Spector S, Rabinovici R: Chest tube
removal: End inspiration or end expiration? J Trauma, Injury,
Infection, Crit Care 50:674-677, 2000
5. Cerfolio RJ, Bass C, Katholi CR: Prospective randomized trial
compares suction versus water seal for air leaks. Ann Thor Surg
71:1613-1617, 2001
6. Weissberg D, Refaely Y: Pneumothorax. Chest 117:1279-1285,
2000
7. Gayer G, Rozenman J, Hoffman C, et al: CT diagnosis of malposi-
tioned chest tubes. Brit J Rad 73:786-790, 2000
8. Tattersall DJ, Traill ZC, Gleeson FV: Chest drains: Does size mat-
ter? Clin Rad 55:415-421, 2000
9. Kudsk KA: The use of chest tubes in trauma and surgical patients.
Contemp Surg 58:76-78, 2002
10. Ganong WF: Review of Medical Physiology (ed 17). San Fran-
cisco: Appleton and Lange, 1995