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

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