CHEST TUBES

This is a review lecture for final year students attached to the University unit &
students preparing for exams. This is not meant for initial study.
Prepared by Dr Dale Maharaj, Lecturer, UWI (updated 05.12.05.)

Tube Anatomy
 Flexible plastic tube
 Clear
 Graduated
 Radio-opaque line
 Multiple holes – last hole is called ‘Sentinel Eye (through which radio-opaque
line passes)
 Straight (stiff) tubes can come with a trocar for percutaneous insertion
 Varying sizes quoted in French (Fr) – outer circumference in mm

Chest anatomy – tube insertion

 Lateral chest wall: Musculature is thinnest & scar is inconspicuous.
 Perform incision between the latissimus dorsi and the pectoralis major i.e. anterior
to mid-axillary line (avoid Long Thoracic Nerve of Bell)
 Pneumothorax: Ideally fourth or fifth interspace.
 Fluid drainage: Seventh or eighth interspace
 Just above the lower rib (avoid VAN in the costal groove)

 Triangle of safety: Anterior border – posterior border of pectoralis major; Posterior border –
anterior border of latissimus dorsi; Inferior border – Nipple line

Positioning:
In mobile patients – sit up and abduct arm away from chest wall
In unconscious patient - elevate bed and rotate arm away
Insertion:
 Informed written consent (explain complications)
 Create sterile field and don protective gear
 Administer local anesthetic (lidocaine)
 Incise skin and subcutaneous tissue between mid and anterior axillary lines
 Blunt Kelly-clamp/finger dissection
 Clamp tube
 2 sutures – purse string and anchoring stitch
 Connect to underwater seal
 Unclamp
 Check for oscillation
 Post-procedural Chest X-ray - Confirm that last hole in tube through radio-opaque
line is in pleural cavity
 DO NOT decompress too quickly as could cause
o Decompression pulmonary edema
o Hemodynamic instability

Indications:
 Drainage of hemothorax, or large pleural effusion of any cause
 Drainage of large pneumothorax (greater than 25%)
 Prophylactic placement of chest tubes in a patient with suspected chest trauma 
before transport to specialized trauma center or positive pressure ventilation 
(prophylactic)
 Flail chest segment requiring ventilator support, severe pulmonary contusion with
effusion
 Empyema
 Chylothorax
 
Contra-indications:
 Coagulopathy or platelet dysfunction warrants caution.
 Known or suspected mesothelioma: can extend through the chest wall at
 thoracostomy site.
 Tuberculous effusion: May convert to mixed pyogenic
infection.
 Known diaphragmatic hernia – caution
 Severe skin infection

Functions of underwater seal:

1. Collection chamber
2. Water seal: allows fluid or water to drain without air being sucked into pleural
space
3. Suction control

Removal:
 Detail procedure to patient
 Sterile field
 Cut anchor stitch
 Pull tube at end of exhalation with Valsalva maneuver.
 Remove tube rapidly and pull purse string suture closed
 Check chest X-ray 12 to 24 hours after removal, for observation of residual air or
fluid.

Complications:
 Puncture of liver or spleen – preventable by insertion between 4th and 5th ribs
 Cardiac puncture – preventable by avoiding trocar
 Passage of tube along chest wall instead of into chest cavity
 Rib damage (esp. in osteoporotic patients)
 Intercostal neurovascular injury and bleeding
 Lung laceration Puncure
 Diaphragm injury – abdominal damage Re-expansion
 Re-expansion pulmonary edema Infection
 Tract infection Clots
Kinks
 Clots or gelatinous inflammatory plugging
 Kinking of the tube.