Chest Tube


  • Large hemothorax or pneumothorax

    • Needle decompress first if tension pneumothorax


  • Materials

    • Local anesthesia

    • Sterile clothing (including face-shield, gown, gloves, hair net)

    • Chest tube

      • Size for adults range 28-32 Fr (no clear evidence for larger tubes)

      • Size for children usually 3 x uncuffed ETT (4+age/4)

        • Infant 8-12 Fr

        • Chidlren 16-24 Fr

      • Load chest tube on back of curved hemostat (Kelly)

      • Clamp opposite end tube (to prevent mess)

    • Scalpel

    • 22G long needle

    • Suture material (1-0, 2-0 non-absorbable silk)

    • Pleurivac or Seal drain system

      • Set up to create water seal (as per manufacturer), attach to suction

    • Vaseline gauze dressing with tape

  • Position

    • Supine or 30 degrees head up

    • Arm secured away (abducted, and elbow flexed)

  • Clean and drape wide area from clavicle to subcostal, sternum to posterior axillary line


  • Identify area above 5th intercostal space and anterior to mid axillary line

    • Usually above and lateral to nipple, pectoral crease, xyphoid process, tip of scapula

  • Anesthetize from below angled superiorly to reach parietal pleura of 4th-5th ICS just above rib (to avoid neurovascular bundle inferior to ribs)

    • Incision >2-3cm parallel to rib with scalpel

  • Hemostat to dissect until reaching pleura

    • "Pop" the pleura, and stretch out pleural incision

    • Use finger to feel lung, check for lung adhesions

  • Advance tube through pleura, and direct posteroinferiorly for fluid and anterosuperiorly for air

    • Unclamp and push in until last hole inside pleural space

  • Check placement

    • See "fog" in tube if unclamp end while patient breathes

    • Rotate tube (check for kinks)

  • Attach collection system (underwater seal drain)

    • May need to cut the end of chest tube to easily attach

    • Consider starting at -20cm H20 of suction

  • Suture and tie many knots


  • Chest X-ray for placement and follow-up

    • Pull-back tube if crosses mediastinum


  • Prepare dressing materials

  • Cut suture

  • Valsalva (hold breath and bear down), or inspiratory pause (if ventilated)

  • Pull tube quickly and seal dressing

  • Leave dressing x 48h