eMedicine Specialties > Clinical Procedures > Cardiothoracic Procedures

Tube Thoracostomy

Updated: Apr 21, 2008

Introduction

Trauma is the leading cause of death for individuals younger than 40 years of age, with approximately 140,000 deaths annually in the United States alone.¹ Of these deaths, thoracic injuries are primarily responsible for 25% of cases² and are a major contributing factor in up to 75% of cases.¹ However, most injuries may be effectively treated with thoracostomy and simple fluid resuscitation.^3,4

Tube thoracostomy is the insertion of a tube (chest tube) into the pleural cavity to drain air, blood, bile, pus, or other fluids.⁵ Whether the accumulation is the result of rapid traumatic filling or insidious malignant seepage, placement of a chest tube allows for continuous, large volume drainage until the underlying pathology can be more formally addressed. The list of specific treatable etiologies is extensive (see Indications), but without intervention, patients are at great risk for major morbidity or mortality.

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Indications

Pneumothorax⁶
- Open or closed
- Simple or tension⁷
Hemothorax⁶
Hemopneumothorax
Hydrothorax
Chylothorax⁸
Empyema
Pleural effusion⁹
Patients with penetrating chest wall injury who are intubated or about to be intubated
Considered for those about to undergo air transport who are at risk for pneumothorax

Contraindications

The need for emergent thoracotomy is an absolute contraindication to tube thoracostomy.
Relative contraindications include the following:
- Coagulopathy
- Pulmonary bullae
- Pulmonary, pleural, or thoracic adhesions
- Loculated pleural effusion or empyema
- Skin infection over the chest tube insertion site

Anesthesia

Systemic analgesia should be used in all conscious patients, unless contraindicated.
Contraindications to use of systemic analgesia can include unstable vital signs and patient in extremis.
Procedural sedation and analgesia should be considered, unless contraindicated. For more information, see Procedural Sedation.
Local anesthesia is described in the Technique section. For more information, see Local Anesthetic Agents, Infiltrative Administration.

Equipment

Chest tube drainage device with water seal (autotransfuser unit is an option)
Suction source and tubing
Sterile gloves
Preparatory solution
Sterile drapes
Surgical marker
Lidocaine 1% with epinephrine
Syringes, 10-20 mL (2)
Needle, 25 gauge (ga), 5/8 in
Needle, 23 ga, 1.5 in; or 27 ga, 1.5 in; for instilling local anesthesia
Blade, No. 10, on a handle
Large and medium Kelly clamps
Large curved Mayo scissors
Large straight suture scissors
Silk or nylon suture, 0 or 1-0
Needle driver
Vaseline gauze
Gauze squares, 4 x 4 in (10)
Sterile adhesive tape, 4 in wide
Chest tube of appropriate size
- Man - 28-32F
- Woman - 28F
- Child - 12-28F
- Infant - 12-16F
- Neonate - 10-12F

Positioning

The patient should be positioned supine or at a 45° angle. (Elevating the patient lessens the risk of diaphragm elevation and consequent misplacement of the chest tube into the abdominal space.)
The arm on the affected side should be abducted and externally rotated, simulating a position in which the palm of the hand is behind the patient's head.
A soft restraint or silk tape can be used to secure the arm in this location. If a restraint is used, make sure that good blood flow to the hand is present.

Technique

Obtain informed consent from the patient or patient’s representative.
Assemble the drainage system and connect it to the suction source. The appearance of bubbles in the water chamber is a sign that the chest tube drainage device is functioning properly.
Position the patient as described above.
Identify the fifth intercostal and the midaxillary line.
- The skin incision is made in between the midaxillary and anterior axillary lines over a rib that is below the intercostal level selected for chest tube insertion.
- A surgical marker can be used to better delineate the anatomy.
Shave excessive hair and apply a preparatory solution to a wide area of the chest wall.

Skin preparation and marking.
Wear sterile gloves, gown, hair cover, and goggles or face shield, and apply sterile drapes to the area.
Administer analgesia.
- Administer a systemic analgesic (unless contraindicated).
- Use the 25-ga needle to inject 5 mL of the local anesthetic solution into the skin overlying the initial skin incision.
  
  Local anesthesia.
- Use the longer needle (23 or, preferably, 27 ga) to infiltrate about 5 mL of the anesthetic solution to a wide area of subcutaneous tissue superior to the expected initial incision. Redirect the needle to the expected course of the chest tube (following the upper border of the rib below the fifth intercostal space), and inject approximately 10 mL of the anesthetic solution into the periosteum (if bone is encountered), intercostal muscle, and the pleura.
- Aspiration of air, blood, pus, or a combination thereof into the syringe confirms that the needle entered the pleural cavity.
Use the No. 10 blade to make a skin incision approximately 4 cm long overlying the rib that is below the desired intercostal level of entry. The skin incision should be in the same direction as the rib itself.

Skin incision.
Use a hemostat or a medium Kelly clamp to bluntly dissect a tract in the subcutaneous tissue by intermittently advancing the closed instrument and opening it.

Blunt dissection down to the intercostal muscle.

Further blunt dissection down to the intercostal muscle.
Palpate the tract with a finger and make sure that the tract ends at the upper border of the rib above the skin incision.

Palpation of the selected intercostal space and the superior margin of its inferior rib.
Adding more local anesthetic to the intercostal muscles and pleura at this time is recommended.
Use a closed large Kelly clamp to pass through the intercostal muscles and parietal pleura and enter into the pleural space.

A closed and locked Kelly clamp is used to enter the chest wall into the pleural cavity. Make sure to guide the clamp over the upper margin of the rib.
- This maneuver requires some force and twisting motion of the tip of the closed Kelly clamp.
- This motion should be done in a controlled manner so the instrument does not enter too far into the chest, which could injure the lung or diaphragm.
- Upon entry into the pleural space, a rush of air or fluid should occur.
The Kelly clamp should be opened (while still inside the pleural space) and then withdrawn so that its jaws enlarge the dissected tract through all layers of the chest wall. This facilitates passage of the chest tube when it is inserted.

Once the Kelly clamp enters the pleural cavity, the clamp should be opened to further enlarge the opening.
Use a sterile, gloved finger to appreciate the size of the tract and to feel for lung tissue and possible adhesions. Rotate the finger 360º to appreciate the presence of dense adhesions that cannot be broken and require placement of the chest tube in a different site, preferably under fluoroscopy (ie, by interventional radiology).

A finger is used to palpate the tract and feel for adhesions before insertion of the chest tube.
Measure the length between the skin incision and the apex of the lung to estimate how far the chest tube should be inserted.
- If desired, place a clamp over the tube to mark the estimated length.
- Some prefer to clamp the tube at a distal point, memorizing the estimated length.
Grasp the proximal (fenestrated) end of the chest tube with the large Kelly clamp and introduce it through the tract and into the thoracic cavity.

The proximal end of the chest tube is held with a Kelly clamp that is used to guide the chest tube through the tract. The distal end of the chest tube should always be clamped until it is connected to the drainage device.
Release the Kelly clamp and continue to advance the chest tube posteriorly and superiorly. Make sure that all of the fenestrated holes in the chest tube are inside the thoracic cavity.
Connect the chest tube to the drainage device (some prefer to cut the distal end of the chest tube to facilitate its connection to the drainage device tubing). Release the cross clamp that is on the chest tube only after the chest tube is connected to the drainage device.

Connection of the chest tube to a drainage system.
Secure the chest tube to the skin using 0 or 1-0 silk or nylon stitches.

A 0 or 1-0 silk or nylon suture is used to secure the chest tube to the skin.
- Two separate through-and-through, simple, interrupted stitches on each side of the chest tube are recommended. This technique ensures tight closure of the skin incision and prevents chest tube dislodgement from routine patient movements.
- Each stitch should be tightly tied to the skin and then wrapped tightly around the chest tube several times and tied again.
Place petrolatum (eg, Vaseline) gauze over the skin incision.

Apply petrolatum (eg, Vaseline) gauze over the skin incision.
Create an occlusive dressing to place over the chest tube by turning regular gauze squares (4 x 4 in) into Y-shaped fenestrated gauze squares and using 4-in adhesive tape to secure them to the chest wall. Make sure to provide enough padding between the chest tube and the chest wall.

Preparation of a Y-shaped fenestrated drain gauze from regular gauze (4 x 4 in).

Apply support gauze dressing around the chest tube and secure it to the chest wall with 4-in adhesive tape.
Obtain a chest radiograph to ensure correct placement of the chest tube.

Chest tube in good position.

Pearls

In cases of high-pressure empyema or pleural effusion, removal of 50-200 mL of fluid using a syringe and a 14-ga needle might prevent high-pressure spraying of the accumulated fluid once the pleural space is entered with the surgical instrument.

A needle and a syringe are used to decompress the pleural cavity in a case of tension empyema.
Since the intercostal vessels and nerve run on the inferior margin of each rib, incision and tunneling should be performed over the rib.
Errors that are commonly observed but easily avoidable include inadequate volume of local anesthetic, failure to wait adequate time for anesthetic to take effect, and too small an incision.

Complications

Improper placement
- Horizontal (over the diaphragm) - Acceptable for hemothorax; should be repositioned for pneumothorax
  
  The chest tube is angulated, overlying the diaphragm.
- Subcutaneous - Must be repositioned
- Placed too far into the chest (against the apical pleura) - Should be retracted
- Placed into the abdominal space - Should be removed
Bleeding
- Local - Usually responds to direct pressure
- Hemothorax (lung vs intercostal artery injury) - Might require thoracotomy if it does not resolve spontaneously
Hemoperitoneum (liver or spleen injury) - Requires emergent laparotomy
Organ penetration (usually requires surgical repair)
- Stomach, colon, or diaphragm - Occurs as a result of unrecognized diaphragmatic hernia
- Lung - Occurs as a result of pleural adhesions or use of a thoracostomy tube trocar
- Liver or spleen – See hemoperitoneum above
Tube dislodgement
Empyema - Chest tube (foreign object) could introduce bacteria into the pleural space
Retained pneumothorax or hemothorax - Might require insertion of a second chest tube

Multimedia

Media file 1: Skin preparation and marking.

Media file 2: Local anesthesia.

Media file 3: Skin incision.

Media file 4: Blunt dissection down to the intercostal muscle.

Media file 5: Further blunt dissection down to the intercostal muscle.

Media file 6: Palpation of the selected intercostal space and the superior margin of its inferior rib.

Media file 7: A closed and locked Kelly clamp is used to enter the chest wall into the pleural cavity. Make sure to guide the clamp over the upper margin of the rib.

Media file 8: Once the Kelly clamp enters the pleural cavity, the clamp should be opened to further enlarge the opening.

Media file 9: A finger is used to palpate the tract and feel for adhesions before insertion of the chest tube.

Media file 10: The proximal end of the chest tube is held with a Kelly clamp that is used to guide the chest tube through the tract. The distal end of the chest tube should always be clamped until it is connected to the drainage device.

Media file 11: Connection of the chest tube to a drainage system.

Media file 12: A 0 or 1-0 silk or nylon suture is used to secure the chest tube to the skin.

Media file 13: Apply petrolatum (eg, Vaseline) gauze over the skin incision.

Media file 14: Preparation of a Y-shaped fenestrated drain gauze from regular gauze (4 x 4 in).

Media file 15: Apply support gauze dressing around the chest tube and secure it to the chest wall with 4-in adhesive tape.

Media file 16: Chest tube in good position.

Media file 17: The chest tube is angulated, overlying the diaphragm.

Media file 18: A needle and a syringe are used to decompress the pleural cavity in a case of tension empyema.

References

Meredith JW, Hoth JJ. Thoracic trauma: when and how to intervene. Surg Clin North Am. Feb 2007;87(1):95-118, vii. [Medline].
Khandhar SJ, Johnson SB, Calhoon JH. Overview of thoracic trauma in the United States. Thorac Surg Clin. Feb 2007;17(1):1-9. [Medline].
Cohn SM. Pulmonary contusion: review of the clinical entity. J Trauma. May 1997;42(5):973-9. [Medline].
Meyer DM. Hemothorax related to trauma. Thorac Surg Clin. Feb 2007;17(1):47-55. [Medline].
Mattox KL, Allen MK. Systematic approach to pneumothorax, haemothorax, pneumomediastinum and subcutaneous emphysema. Injury. Sep 1986;17(5):309-12. [Medline].
Bailey RC. Complications of tube thoracostomy in trauma. J Accid Emerg Med. Mar 2000;17(2):111-4. [Medline].
Leigh-Smith S, Harris T. Tension pneumothorax--time for a re-think?. Emerg Med J. Jan 2005;22(1):8-16. [Medline].
Tsukahara K, Kawabata K, Mitani H, Yoshimoto S, Sugitani I, Yonekawa H, et al. Three cases of bilateral chylothorax developing after neck dissection. Auris Nasus Larynx. Dec 2007;34(4):573-6. [Medline].
Muzumdar H, Arens R. Pleural fluid. Pediatr Rev. Dec 2007;28(12):462-4. [Medline].
Roberts JR, Hedges RJ, eds. Clinical Procedures in Emergency Medicine. 4th. Philadelphia: WB Saunders Company; 2004.
Reichman EF, Simon RR, eds. Emergency Medicine Procedures. 1st. Columbus, OH: McGraw-Hill Professional; 2003.

Keywords

tube thoracostomy, chest tube, tube chest, tube drain, pneumothorax, hemothorax, empyema, pleural cavity, hemopneumothorax, hydrothorax, chylothorax, pleural effusion, penetrating chest wall injury, systemic analgesia, midaxillary line, subcutaneous tract, tract dissection, intercostal muscles, pleural space, high-pressure empyema, pleural effusion, hemoperitoneum

Contributor Information and Disclosures

Author

Gil Z Shlamovitz, MD, Assistant Professor of Emergency Medicine, University of Connecticut School of Medicine; Attending Physician, Emergency Department, Windham Community Memorial Hospital, Willimantic, CT; Attending Physician, Emergency Department, Hartford Hospital, Hartford, CT
Gil Z Shlamovitz, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

Luis M Lovato, MD, Assistant Clinical Professor, David Geffen School of Medicine at UCLA; Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center
Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

CME Editor

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: eMedicine.com, Inc. Consulting fee Consulting

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the assistance of Lars Grimm with the literature review and referencing for this article.

Further Reading