Chest Tube Insertion

General remarks

  • Adequate training for the insertion of chest drains in a trauma setting reduces the occurrence of procedure-related complications.
  • Prophylactic antibiotics reduces the risks of infectious complications and empyema.
  • For drainage of a traumatic pneumo- or hemothorax a large drain (28-36 French) is advised. The preferential insertion site is the 5th intercostal space in the midaxillary line ('Safe Triangle').
  • Ideally the chest tube should be aimed apically for a pneumothorax or basally for fluid. However, an effectively functioning drain should not be repositioned only because of its radiographic position.
  • Drainage systems consist of a collection bottle, water seal and a suction control. Suction applied at 15-20 cm H2O is recommended for adequate drainage.
  • Detection of occult air leaks before removal of the drain can be performed by temporary water seal or clamping of the drain followed by a chest x-ray.
  • Removal of a chest drain at end-inspiration is as secure as end-exspiration.

  • Step by step

    1. Positioning patient; ideally with the arm on the side of the lesion behind patient’s head for optimal exposure of the axillary region
    2. Identify safe triangle and insertion site, 5th intercostal space in the midaxillary line
    3. Aseptic technique must be applied
    4. Local anaesthesia.
    5. Skin incision parallel to the rib
    6. Blunt dissection over the rib to avoid vascular or nerve damage
    7. Proceed until the pleural cavity is reached
    8. Drain insertion and positioning (aim apically for pneumothorax or basally for fluid)
    9. Apply stay and (future) closing suture
    10. Connect drain to drainage system
    11. Apply transparent dressing

    1. American College of Surgeons. Advanced Trauma Life Support Program for Doctors. 7th ed. Chicago: American College of Surgeons; 2004Laws D, Neville E, Duffy J. BTS guidelines for the insertion of a chest drain. Thorax. 2003;58:ii53-59
    2. What size chest tube? What drainage system is ideal? And other chest tube management questions. Baumann MH. Curr Opin Pulm Med. 2003;9:276-281
    3. Role of prophylactic antibiotics for tube thoracostomy in chest trauma. Gonzalez RP, Holevar MR. Am Surg. 1998;64:617-621
    4. Meta-analysis of antibiotics in tube thoracostomy. Evans JT, Green JD, Carlin PE, Barrett LO. Am Surg. 1995;61:215-219.
    5. Chest tube removal: end-inspiration or end-expiration? Bell RL, Ovadia P, Abdullah F, Spector S, Rabinovici R. J Trauma. 2001;50:674-677