P R OC E D UR E 2 0

Chest Tube Placement (Perform)

Paula A. Lusardi, S usan S . S c ott and Finn S c ott

PURPOSE:
Chest tubes are placed for the removal or drainage of air, blood, or fluid from the intrapleural or mediastinal
space. They also are used to introduce sclerosing agents into the pleural space to prevent a reaccumulation of
fluid.

PREREQUISITE NURSING KNOWLEDGE

• The thoracic cavity, in normal conditions, is a closed airspace. Any disruption results in the loss of negative pressure
within the intrapleural space. Air or fluid that enters the space competes with the lung, resulting in collapse of the
lung. Associated conditions are the result of disease, injury, surgery, or iatrogenic causes.
• Chest tubes are sterile flexible vinyl or silicone nonthrombogenic catheters approximately 20 inches (51 cm) long,
varying in size from 12F to 40F. The size of the tube placed is determined by the condition. Chest tubes inserted for
traumatic hemopneumothorax or hemothorax (blood) should be large (36F to 40F). Medium tubes (24F to 36F)
should be used for fluid accumulation (pleural effusions). Tubes inserted for pneumothorax (air) should be small (12F
to 24F).2
• Indications for chest tube insertion include the following:
Pneumothorax (collection of air in the pleural space)
Hemothorax (collection of blood)
Hemopneumothorax (accumulation of air and blood in the pleural space)
Tension pneumothorax
Thoracotomy (e.g., open heart surgery, pneumonectomy)
Pyothorax or empyema (collection of pus)
Chylothorax (collection of chyle from the thoracic duct)
Cholothorax (collection of fluid containing bile)
Hydrothorax (collection of noninflammatory serous fluid)
Pleural effusion
• A pneumothorax may be classified as an open, closed, or tension pneumothorax.
Open pneumothorax: The chest wall and the pleural space are penetrated, which allows air to enter the pleural space,
as in penetrating injury or trauma, surgical incision in the thoracic cavity (i.e., thoracotomy), or complication of
surgical treatment (e.g., unintentional puncture during invasive procedures, such as thoracentesis or central venous
catheter insertion).
Closed pneumothorax: The pleural space is penetrated, but the chest wall is intact, which allows air to enter the
pleural space from within the lung, as in spontaneous pneumothorax. A closed pneumothorax occurs without
apparent injury and often is seen in individuals with chronic lung disorders (e.g., emphysema, cystic fibrosis,
tuberculosis, necrotizing pneumonia); in young, tall men who have a greater than normal height-to-width chest
ratio; after blunt traumatic injury; or iatrogenically, occurring as a complication of medical treatment (e.g.,
intermittent positive-pressure breathing [IPPB], mechanical ventilation with positive end-expiratory pressure
[PEEP]).
Tension pneumothorax: Air leaks into the pleural space through a tear in the lung and has no means to escape from
the pleural cavity, creating a one-way valve effect. With each breath the patient takes, air accumulates, pressure
within the pleural space increases, and the lung collapses. This condition causes the mediastinal structures (i.e.,
 heart, great vessels, and trachea) to be compressed and shift to the opposite or unaffected side of the chest. Venous
return and cardiac output are impeded, and collapse of the unaffected lung is possible. This life-threatening
emergency requires prompt recognition and intervention.
Special applications: Chest tubes can be used to instill anesthetic solutions and sclerosing agents.
• Lung that is densely adherent to the chest wall throughout the hemithorax is an absolute contraindication to chest
tube therapy.4
• Use of chest tubes in patients with multiple adhesions, giant blebs, or coagulopathies is carefully considered; however,
these relative contraindications are superseded by the need to reexpand the lung. When possible, any coagulopathy or
platelet defect should be corrected before chest tube insertion. The differential diagnosis between a pneumothorax
and bullous disease necessitates careful radiologic assessment.4
• The tube size and insertion site selected for the chest tube are determined by the indication.4 If draining air, the tube is
placed near the apex of the lung (second intercostal space); if draining fluid, the tube is placed near the base of the
lung (fourth or fifth intercostal space; Fig. 20-1).

FIGURE 20-1 Standard sites for tube thoracostomy. A, The second intercostal space, midclavicular line. B, The fourth or fifth intercostal space, midaxillary
line. Most clinicians prefer midaxillary line placement for all chest tubes, regardless of pathology. Placement of the tube too far posteriorly does not allow the
patient to lie dow n comfortably. (From Roberts JR, Hedges JR, editors: Clinicals in emergency medicine, ed 4, Philadelphia, 2004, Saunders.)

When the tube is in place, the tube is sutured to the skin to prevent displacement, and an occlusive dressing is
applied (see Fig. 21-1). The chest tube also is connected to a chest drainage system (see Procedure 24) to remove air
and fluid from the pleural space, which facilitates reexpansion of the collapsed lung. All connection points are
 secured with tape or zip ties (Parham-Martin bands) to ensure that the system remains airtight (see Fig. 21-2).
The water-seal chamber should bubble gently immediately on insertion of the chest tube during expiration and with
coughing. Continuous bubbling in this chamber indicates a leak within the patient or in the chest drainage system.
Fluctuations in the water level in the water-seal chamber of 5 to 10 cm, rising during inhalation and falling during
expiration, should be observed with spontaneous respirations. If the patient is on mechanical ventilation, the
pattern of fluctuation is just the opposite. Any suction applied must be disconnected temporarily to assess correctly
for fluctuations in the water-seal chamber.
Mediastinal tubes generally are placed in the operating room by a surgeon after cardiac surgery.

EQUIPMENT
• Antiseptic solution or swab packets
• Caps, masks, sterile gloves, gowns, drapes
• Protective eyewear (goggles)
• Local anesthetic: 1% lidocaine solution (without epinephrine)
• Tube thoracotomy insertion tray
Sterile towels, 4 × 4 sterile gauze
Scalpel with no. 10 blade
Two Kelly clamps, curved clamps
Needle holder
Monofilament or silk suture material with cutting needle
• Sterile basin or medicine cup
• Suture scissors
• Two hemostats
• 10-mL syringe with 20-gauge 1½-inch needle
• 5-mL syringe with 25-gauge 1-inch needle
• Thoracotomy tubes (12F to 40F, as appropriate)
• Closed chest drainage system
• Suction source
• Suction connector and connecting tubing (usually 6 feet for each tube)
• 1-inch adhesive tape or zip ties (Parham-Martin bands)
• Dressing materials
4 × 4 gauze pads
Slit drain sponges
Petrolatum gauze
Tape
Commercial securing device

PATIENT AND FAMILY EDUCATION

• Explain the procedure (if patient condition and circumstances allow) and the reason for the chest tube insertion.
Rationale: This communication identifies patient and family knowledge deficits concerning the patient’s condition,
expected benefits, and potential risks and allows time for questions to clarify information and to voice concerns.
Explanations decrease patient anxiety and enhance cooperation.
• Explain that the patient’s participation during the procedure is to remain as immobile as possible and do relaxed
breathing. Rationale: This explanation facilitates insertion of the chest tube and prevents complications during
insertion.
• After the procedure, instruct the patient to sit in a semi-Fowler’s position (unless contraindicated). Rationale: This
position facilitates drainage from the lung by allowing air to rise and fluid to settle to be removed via the chest tube.
This position also makes breathing easier.
• Instruct the patient to turn and change position every 2 hours. The patient may lie on the side with the chest tube but
should keep the tubing free of kinks. Rationale: Turning and changing position prevent complications related to
immobility and retained pulmonary secretions. Keeping the tube free of kinks maintains patency of the tube,
facilitates drainage, and prevents the accumulation of pressure within the pleural space that interferes with lung
reexpansion.
• Instruct the patient to cough and deep breathe, with splinting of the affected side. Rationale: Coughing and deep
breathing increase pressure within the pleural space, facilitating drainage, promoting lung reexpansion, and
preventing respiratory complications associated with retained secretions. The application of firm pressure over the
 chest tube insertion site (i.e., splinting) decreases pain and discomfort.
• Encourage active or passive range-of-motion exercises of the arm on the affected side. Rationale: The patient may
limit movement of the arm on the affected side to decrease the discomfort at the insertion site, which results in joint
discomfort and potential joint contractures.
• Instruct the patient and family about activity as prescribed while maintaining the drainage system below the level of
the chest. Rationale: This activity facilitates gravity drainage and prevents backflow and potential infectious
contamination into the pleural space.
• Instruct the patient about the availability of prescribed analgesic medication and other pain relief strategies.
Rationale: Pain relief ensures comfort and facilitates coughing, deep breathing, positioning, range of motion, and
recuperation.

PATIENT ASSESSMENT AND PREPARATION

Patient Assessment
• Assess for significant medical history or injury, including chronic lung disease, spontaneous pneumothorax,
hemothorax, pulmonary disease, therapeutic procedures, and mechanism of injury. Rationale: Medical history or
injury may provide the etiologic basis for the occurrence of pneumothorax, empyema, pleural effusion, or
chylothorax.
• Evaluate diagnostic test results (if patient’s condition does not necessitate immediate intervention), including chest
radiograph and arterial blood gases. Rationale: Diagnostic testing confirms the presence of air or fluid in the pleural
space, a collapsed lung, hypoxemia, and respiratory compromise.
• Perform hand hygiene. Rationale: Reduces the transmission of microorganisms and body secretions (Standard
Precautions).
• Assess baseline cardiopulmonary status for signs and symptoms that necessitate chest tube insertion3 :
Tachypnea
Decreased or absent breath sounds on affected side
Crackles adjacent to the affected area
Shortness of breath, dyspnea
Asymmetrical chest excursion with respirations
Cyanosis
Decreased oxygen saturation
Hyperresonance in the affected side (pneumothorax)
Subcutaneous emphysema (pneumothorax)
Dullness or flatness in the affected side (hemothorax, pleural effusion, empyema, chylothorax)
Sudden, sharp chest pain
Anxiety, restlessness, apprehension
Tachycardia
Hypotension
Dysrhythmias
Tracheal deviation to the unaffected side (tension pneumothorax)
Neck vein distention (tension pneumothorax)
Muffled heart sounds (tension pneumothorax)
Rationale: Accurate assessment of signs and symptoms allows for prompt recognition and treatment. Baseline
assessment provides comparison data for evaluation of changes and outcomes of treatment.

Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient understands pre-procedural teachings. Answer questions as they arise, and reinforce
information as needed. Rationale: This communication evaluates and reinforces understanding of previously
taught information.
• Obtain informed consent if circumstances allow. Rationale: Invasive procedures, unless performed with implied
consent in a life-threatening situation, require written consent of the patient or significant other.
• Determine the insertion site and mark the skin with an indelible marker. Rationale: The insertion site is determined
by the indication for the chest tube. For air, use the second intercostal space; for fluid, use the fifth or sixth intercostal
space.
 • Determine the size of chest tube needed. Rationale: Evacuation of air necessitates a smaller tube; evacuation of fluid
necessitates larger tubes.
• Assist the patient to the lateral, supine (for pneumothorax), or semi-Fowler’s position (for hemothorax).6 Rationale:
This positioning enhances accessibility to the insertion site for positioning of the chest tube.
• Administer prescribed analgesics or sedatives as needed; follow institutional policy for moderate or procedural
sedation. Rationale: Analgesics and sedatives reduce the discomfort and anxiety experienced and facilitate patient
cooperation.
• Administer oxygen and monitor pulse oximeter or end-tidal carbon dioxide level. Rationale: Real-time assessment
of patient’s respiratory status during the procedure is provided.
• Ensure patient has a patent intravenous (IV) access. Rationale: This access provides a route for analgesic, sedation,
and emergency medications.
Procedure for Performing Chest Tube Placement
FIGURE 20-2 Insertion of a chest tube can be relatively painless w ith proper infiltration of the skin and pleura w ith local anesthetic. The liberal use of
buffered 1% lidocaine w ithout epinephrine (maximal lidocaine dose, 5 mg/kg) is recommended. (From Roberts JR, Hedges JR, editors: Clinicals in emergency medicine,
ed 4, Philadelphia, 2004, Saunders.)
FIGURE 20-3 Transverse skin incision is made directly over the inferior aspect of the anesthetized rib dow n to the subcutaneous tissue. (From Dumire SM,
Paris PM: Atlas of emergency procedures, Philadelphia, 1994, Saunders.)
FIGURE 20-4 Blunt dissection is accomplished w ith forcing a closed clamp through the incision and using an opening-and-spreading maneuver to create a
tunnel to the pleura. ICS, Intercostal space.

FIGURE 20-5 Just over the superior portion of the rib, close the clamp and push w ith steady pressure into the pleura. (From Dumire SM, Paris PM: Atlas of
emergency procedures, Philadelphia, 1994, Saunders.)
 FIGURE 20-6 The tube is grasped w ith the curved clamp, w ith the tube tip protruding from the jaw s. (From Roberts JR, Hedges JR, editors: Clinicals in emergency
medicine, ed 4, Philadelphia, 2004, Saunders.)

FIGURE 20-7 A “stay” suture is placed first next to the tube to close the skin incision. A, The knot is tied securely, and the ends, w hich subsequently are
w rapped around the chest tube, are left long. B, The ends of the suture are w ound tw ice about the tube, tightly enough to indent the tube slightly, and are
tied securely. (From Roberts JR, Hedges JR, editors: Clinicals in emergency medicine, ed 4, Philadelphia, 2004, Saunders.)

References
1. Buchman, TG, Hall, BL, Bowling, WM, et al. Thoracic trauma. In: Tininalli JE, Kelen DG, Stapczynski JS, eds.
Emergency medicine: a comprehensive guide. ed 6. New York: McGraw-Hill; 2004:1595–1612.
2. Dev, SP, Nascimiento, B, Simone, C, et al. Chest-tube -insertion. N Engl J Med. 2007; 357:e15.
3. Irwin, RS, Rippe, JM. Intensive care medicine. Philadelphia: Wolters Kluwer/Lippincott & -Williams & Wilkins;
2008.
4. Laws, D, Neville, E, Duffy, J, BTS guidelines for insertion of a chest drain. Suppl II. Thorax 2003; 58:ii53–ii59.
5. May, G, Bartram, T. The use of intrapleural anaesthetic to reduce the pain of chest drain insertion. Emerg Med J.
2007; 24:300–301.
6. Roberts. Clinical procedures in emergency medicine, ed 4. Philadelphia: Saunders; 2004.
7. Sullivan, B. Nursing management of patients with a chest drain. Br J Nurs. 2008; 17(6):388–393.
8. Thompson, JM, McFarland, GK, Hirsh, JE, et al. Mosby’s clinical nursing,, ed 5. St Louis: Mosby; 2002.

Additional Readings
Argall, J. S eldinger tec hnique c hest drains and c omplic ation rate. Emerg Med J. 2003; 20:169–170.
Charnoc kY, Evans, D, Nursing management of c hest drains. a systematic review. Aust Crit Care 2001; 14:156–160.
Coughlin, AM, Parc hinsky, C. Go with the flow of c hest tube therapy. Nursing. 2006; 36:36–42.
Ellis, H. The applied anatomy of c hest drain insertion. Br J Hosp Med (London). 2007; 68:M44–45.
Frankel, TL, Hill, PC, S tamou, S C, et al. S ilastic drains vs c onventional c hest tubes after c oronary artery bypass. Chest. 2003; 124:108–113.
Gareeboo, S , S ingh, S , Tube thorac ostomy. how to insert a c hest drain. Br J Hosp Med (London) 2006; 67:M16–18.
Lehwaldt, D, Timmins, F, Nurses’ knowledge of c hest drain c are. an exploratory desc riptive survey. Nurs Crit Care 2005; 10:192–200.
Zgoda, MA, Lunn, W, Ashiku, S , et al, Minimally invasive -tec hniques. direc t visual guidanc e for c hest tube -plac ement through a single-port thorac osc opya -
novel tec hnique. Chest 2005; 127:1805–1807.

This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)

with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institutional standard.