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
  • 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