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Tube Thoracostomy

by Noah Lechtzin, MD, MHS

Tube thoracostomy is insertion of a tube into the pleural space. It is used to drain air or fluid from the chest (eg, for large or recurrent effusion refractory to thoracentesis, pneumothorax, complicated parapneumonic effusions, empyema, or hemothorax) and to do pleurodesis or fibrinolytic adhesiolysis.


Chest tube insertion is best done by a physician trained in the procedure. Other physicians can handle emergency situations (eg, tension pneumothorax) using a needle and syringe. Tube insertion requires 1 or 2 hemostats or Kelly clamps, a silk suture, gauze dressing, and a chest tube. Recommended tube sizes are 16 to 24 French (Fr) for pneumothorax; 20 to 24 Fr for malignant pleural effusion; 28 to 36 Fr for bronchopleural fistula, complicated parapneumonic effusions, and empyema; and 32 to 40 Fr for hemothorax.

The insertion site and patient position depend on whether air or fluid is being drained. For pneumothorax, the tube is usually inserted in the 4th intercostal space and for other indications in the 5th or 6th intercostal space, in the midaxillary line with the ipsilateral arm abducted above the head.

No specific patient preparation is necessary except, in some cases, conscious sedation. Under sterile conditions, the skin, subcutaneous tissue, rib periosteum, and parietal pleura are locally anesthetized, more generously than for thoracentesis (see Thoracentesis). Proper location is confirmed by return of air or fluid in the anesthetic syringe. A purse-string suture can be placed but not yet tied around the site while the anesthetic takes effect. A 2-cm skin incision is made, and the intercostal soft tissue down to the pleura is then bluntly dissected by advancing a clamped hemostat or Kelly clamp and opening it; the pleura is then perforated with the clamped instrument and opened in the same way. A finger can be used to widen the tract and confirm entry into the pleural space. The chest tube, with a clamp grasping the tip, is inserted through the tract and directed inferoposteriorly for effusions, or apically for pneumothorax, until all of the tube’s holes are inside the chest wall. The purse-string suture is closed, the tube is sutured to the chest wall, and a sterile dressing with petroleum gauze to help seal the wound is placed over the site.

The tube is connected to water seal to prevent air from entering the chest through the tube and to allow drainage without suction (for effusions or empyema) or with suction (for pneumothorax). Posteroanterior and lateral chest x-rays are obtained after insertion to check the tube’s position.

The tube is removed when the condition for which it was placed resolves. In the case of pneumothorax, suction is stopped and the tube is placed on water seal for several hours to ensure that the air leak has stopped and that the lung remains expanded. At the moment of removal, the patient is asked to take a deep breath and then to forcibly exhale; the tube is removed during exhalation and the site is covered with petroleum gauze, a sequence that reduces the chance of pneumothorax during removal. For effusions or hemothorax, the tube is typically removed when the drainage is < 100 mL/day.


Complications include the following:

  • Malpositioning of the tube in the lung parenchyma, in the lobar fissure, under the diaphragm, or subcutaneously

  • Clotting, kinking, or dislodgement of the tube, requiring replacement

  • Re-expansion pulmonary edema

  • Subcutaneous emphysema

  • Infection of residual pleural fluid or recurrent effusion

  • Pulmonary or diaphragmatic laceration

  • Rarely perforation of other structures

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