Expected finding in a patient with a tube thoracostomy connected to a chest drainage system

What Is a Chest Tube?

A chest tube is a plastic tube that is used to drain fluid or air from the chest. Air or fluid (for example blood or pus) that collects in the space between the lungs and chest wall (the pleural space) can cause the lung to collapse. Chest tubes can be inserted at the end of a surgical procedure while a patient is still asleep from anesthesia or at the bedside using a local pain killer and some sedation. Chest tubes come in a variety of shapes and sizes. Depending on what they are needed for, they can range in diameter from as small as a shoelace to as large as a highlighter.

Chest tubes are usually connected to drainage systems that collect fluid and allow air to escape from the chest. These systems can be allowed to drain passively or can have suction applied to them.

What to Expect

When chest tubes are placed in a patient who is awake, patients can expect to receive some form of local pain killer where the chest tube will be inserted. Often, patients are also given medicine to help ease anxiety. Although efforts are made to make the procedure more tolerable, patients still usually experience some discomfort. Some chest tubes are inserted after the skin and muscles of the chest wall are cut and gently spread apart. Some chest tubes are inserted after a wire is placed into the chest through a needle and the wire acts as a track for the tube to follow. In both cases, patients often report some discomfort after the procedure as the tube lies on the ribs and moves slightly with each breath. Luckily, this discomfort is usually temporary.

The main goal of this procedure is drainage of the pleural space. Patients can expect to see or feel the fluid or air leaving the chest. Often, patients may feel the collapsed lung re-expanding. A chest X-ray will be performed after the procedure to see how much air or fluid has been drained, how much the lung has re-expanded, and to determine the final position of the chest tube. Chest tubes remain in place for a variable number of days. Usually, when the amount of fluid draining from the tube is low, or there is no more air escaping through the tube, it can be removed.

Like any surgical procedure, the primary risks with chest tube placement are bleeding and infection. Practitioners are careful to avoid the blood vessels that run on the underside of the ribs during placement. In order to avoid introducing an infection, the entire procedure is performed in a sterile fashion. The other major risks involve damage to the other structures in the chest, like the lungs and heart. Though injuries to these structures are very uncommon, they can be serious.

Chest tubes are kept in place by stitches and are covered by a sterile dressing. Mild discomfort at the site of insertion is common. If you have severe pain or difficulty breathing, call for help right away. The duration for which a chest tube is needed varies but is usually a few days. In certain situations, patients can be sent home with a chest tube; however, in most cases they are removed before discharge from the hospital. Your healthcare provider will remove the chest tube by cutting the stitches that hold it in place. Mild discomfort during removal may occur.

What Are the Risks?

• Pain during insertion and after placement of chest tube: Although pain during insertion and mild discomfort after placement are common, your healthcare provider can help minimize these effects with pain medicines.
• Infection
• Improper placement
• Dislodged chest tube
• Collapsed lung after removal of chest tube
• Bleeding at the site of insertion
• Bleeding into the pleural space (space around lungs) or within the abdomen
• Injury to the lung
• Injury to other organs, such as heart, spleen, liver, diaphragm

Your healthcare provider will take measures to minimize the risk of these complications. Serious complications are uncommon.

Obtain informed consent from the patient or patient’s representative except when urgent placement is required.

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 patient using two identifiers (eg, name and date of birth). If possible, match the patient's identifiers at his or her bed side with the identifiers present on a chest radiographs or computerized tomograms (CT) that was recently performed. Clearly mark the site of chest tube insertion (right or left).

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 as shown below.

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, as shown in the image below. 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. 11 or 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.

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, as shown.

Palpate the tract with a finger as shown, and make sure that the tract ends at the upper border of the rib above the skin incision. Insertion of the chest tube as close as possible to the upper border of the rib will minimize the risks of injury to the nerve and blood vessels that follow the lower border of each 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, as shown.

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 as shown. This facilitates passage of the chest tube when it is inserted.

Use a sterile, gloved finger to appreciate the size of the tract and to feel for lung tissue and possible adhesions, as shown in the image below. 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).

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 as shown.

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 as shown (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.

Before securing the tube with stitches, look for a respiration-related swing in the fluid level of the water seal device to confirm correct intrathoracic placement.

Secure the chest tube to the skin using 0 or 1-0 silk or nylon stitches, as depicted below.

For securing sutures, 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 routine patient movements from dislodging the chest tube. Each stitch should be tightly tied to the skin, then wrapped tightly around the chest tube several times to cause slight indentation, and then tied again. Sealing suture: A central vertical mattress stitch with ends left long and knotted together can be placed to allow for sealing of the tract once the chest tube is removed.

Place petrolatum (eg, Vaseline) gauze over the skin incision as shown.

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, as shown below. Make sure to provide enough padding between the chest tube and the chest wall.

Strap the emerging chest tube on to the lower trunk with a "mesentry" fold of adhesive tape, as this avoids kinking of the tube as it passes through the chest wall. It also helps reduce wound site pain and discomfort for the patient. All connections are then taped in their long axis to avoid disconnections.

Obtain a chest radiograph, like the one below, to ensure correct placement of the chest tube.

See Tube Thoracostomy Management for removal techniques.

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