Chest drain insertion, or tube thoracostomy, is a fundamental procedure for managing conditions involving the pleural space. It involves placing a tube through the chest wall to drain air, fluid (blood, pus, or effusion), or to aid lung re-expansion after surgery.
While common, it is a high-risk procedure. Incorrect placement can lead to significant morbidity and even mortality. This guide provides a comprehensive overview of the indications, essential procedural steps, and critical management pearls.
A note on safety: This procedure should only be performed by, or under the direct supervision of, a trained and credentialed clinician. Studies note that ultrasound-guided insertion is associated with lower complication rates and should be used when available.
Indications
The urgency of insertion depends on the patient’s degree of physiological compromise. Key indications include:
- Pneumothorax (PTX): Draining air from the pleural space (though not all pneumothoraces require a drain).
- Pleural Fluid:
- Malignant Pleural Effusion: Fluid accumulation due to cancer.
- Empyema: Pus in the pleural space.
- Complicated Parapneumonic Effusion: An infected effusion related to pneumonia.
- Hemothorax: Blood in the pleural space, often due to trauma.
- Post-operative: Following thoracic, oesophageal, or cardiothoracic surgery to drain air and fluid.
Critical Risks & Pre-Procedure Planning
Before you begin, you must be aware of the significant potential complications.
Key Complications
- Incorrect Placement: The drain may be placed outside the pleura (subcutaneously), within the lung parenchyma, in an interlobular fissure, or kinked.
- Organ Injury: A misplaced drain can perforate the heart, liver, spleen, or diaphragm.
- Vascular Injury: Laceration of the intercostal artery (which runs under the rib) can cause life-threatening bleeding.
- Bleeding: Always ensure the patient has no uncorrected coagulopathy.
- Infection: Poor aseptic technique can lead to a secondary empyema.
CRITICAL WARNING: A trocar must NEVER be used for primary insertion. The risk of “spearing” a vital organ is unacceptably high. The procedure must be performed using blunt dissection.
Pre-Procedure Checklist
- Consent: Obtain and document informed consent. In a dire emergency where the patient cannot consent, this may be bypassed, but the urgency must be documented.
- Patient & Site Verification: Confirm the patient’s identity. Confirm the correct site by reviewing clinical signs (percussion, auscultation) and the most recent chest X-ray or ultrasound.
- Positioning: The standard position is semi-erect (30-60°) with the patient lying back. The arm on the affected side should be abducted and placed over or behind the head to “open up” the rib spaces.
- Site Selection: The “Safe Triangle” The most common and safest insertion site is the 4th or 5th intercostal space, in the mid-axillary to anterior-axillary line. This area is known as the “safe triangle.”Its borders are:
- Anterior: The lateral edge of the pectoralis major.
- Posterior: The anterior edge of the latissimus dorsi.
- Inferior: A line superior to the horizontal level of the nipple (approx. 5th ICS).
- Apex: The axilla.
- Anesthesia & Asepsis:
- Use a full aseptic technique (sterile gown, gloves, mask, drapes, and skin prep).
- Chest drain insertion is extremely painful. Generous local anesthesia is essential.
- Infiltrate 10-15 ml of 1% lignocaine along the entire intended track, including the skin, muscle, periosteum (of the rib below your target space), and the parietal pleura. Fig: A and B.
- Pro-tip: The parietal pleura is the toughest and most sensitive layer. Consider administering an additional bolus of anesthetic just before pushing through it.
- For stable patients, consider parenteral analgesics or procedural sedation.
Insertion Techniques
The choice of drain (small-bore vs. large-bore) and technique depends on the indication.
- Small-Bore (e.g., 10-16F): Inserted via the Seldinger (guidewire) technique. Best for simple pneumothorax or non-viscous (thin) effusions.
- Large-Bore (e.g., 26F and above): Inserted via the surgical (blunt dissection) technique. Required for traumatic haemothorax (blood clots) or empyema (thick pus).
Technique 1: Seldinger (Guidewire) Insertion
- After anesthetizing, advance the introducer needle (attached to a syringe) into the pleural space while aspirating. A flash of air or fluid confirms entry.
- Thread the guidewire through the needle into the chest.
- Remove the needle, leaving the wire in place.
- Pass the dilator over the wire to create the tract (this may require a small skin nick).
- Remove the dilator, leaving the wire.
- Thread the chest drain over the wire into the pleural space.
- Remove the wire, suture the drain, and attach it to the drainage system.
Technique 2: Surgical (Blunt Dissection) Insertion
This is the classic technique, essential for large-bore drains.
- Incision: Make a 3-5 cm transverse skin incision over the rib at or one below your target intercostal space.
- Blunt Dissection: Insert a large Kelly clamp and bluntly dissect upwards through the subcutaneous tissue and intercostal muscles, aiming to pass just over the top of the rib. This is the single most important step to avoid the neurovascular bundle.
- Pleural Entry: Close the clamp. Apply firm, controlled pressure to push the clamp tips through the tough parietal pleura. A “pop” is often felt.
- Spread: Open the jaws of the clamp widely (parallel to the ribs) to enlarge the hole.
- The Finger Sweep (Critical Safety Step): Remove the clamp and insert your sterile, gloved finger into the tract and through the pleura.
- Sweep 360 degrees inside the chest cavity.
- This confirms you are in the pleural space (not the liver or spleen), sweeps away any local adhesions, and ensures the lung is not directly against the entry site.
- Tube Insertion: Pass the chest tube (either grasped with the clamp or guided alongside your finger) into the pleural space. Direct it posteriorly and superiorly toward the apex.
- Final Check: Ensure all drainage holes on the tube are fully inside the chest cavity.
Securing the Drain & Post-Procedure Management
Securing the Tube
The drain must be securely fixed to prevent dislodgement or air leaks.
- Suture: Use a strong suture (e.g., 0 or 1-0 Silk or Nylon) to close the incision and anchor the tube. A “stay suture” or horizontal mattress suture is often used. The suture should be tied tightly enough to indent the tube slightly. Avoid purse-string sutures, as they leave an unsightly scar.
- Dressing: Apply an occlusive dressing (e.g., petrolatum-impregnated gauze) directly at the insertion site to seal it. Cover with sterile gauze and secure with wide, adhesive tape.
Connecting the Drain
- Attach the drain to an underwater seal drainage system.
- This system acts as a one-way valve, allowing air and fluid out but not back in.
- The collection chamber must be kept below the level of the patient’s chest at all times.
Post-Procedure Checks
- CXR: Obtain a post-procedure chest X-ray immediately to confirm correct placement and assess lung re-expansion.
- Observe the Drain:
- Swinging: The fluid in the drainage tube should rise on inspiration and fall on expiration (in a spontaneously breathing patient). This is called “swinging” or “tidaling” and confirms the drain is in the pleural space and patent.
- Bubbling: In a patient with a pneumothorax, bubbling in the water seal chamber indicates an ongoing air leak. This is expected. (If the drain was placed only for fluid, bubbling is abnormal).
- No Swinging? If the fluid does not swing, the drain may be blocked, kinked, or no longer in the pleural space.
Key Management Rules
- Clamping:
- NEVER clamp a chest drain inserted for a pneumothorax. If the patient has an ongoing air leak, clamping the tube can quickly lead to a life-threatening tension pneumothorax.
- Drains may be briefly clamped only to change a full drainage bottle or (if draining fluid) to control the rate.
- Large Effusions: Draining large volumes of fluid too quickly can cause re-expansion pulmonary oedema.
- Limit initial drainage to 1–1.5 Litres.
- After this, clamp the drain for an hour or two before resuming drainage.
- Stop drainage immediately if the patient develops a cough, chest tightness, or dyspnoea.
- Trauma/Bleeding: If the drain is for a hemothorax, monitor output closely. Urgent surgical review is required for:
- Initial blood loss >1500 ml.
- Continued bleeding >200 ml/hour for 2-4 hours.
- Antibiotics: For drains placed due to trauma (e.g., hemothorax), 24 hours of prophylactic antibiotics (e.g., a first-generation cephalosporin) is recommended to reduce infection rates.
Drain Removal
The drain is removed once the underlying issue is resolved (e.g., lung is fully re-expanded and any air leak has stopped).
- Provide adequate analgesia.
- Using an aseptic technique, cut the anchor suture.
- Ask the patient to perform a Valsalva manoeuvre (bear down) or take a deep breath in and hold it. This raises intrathoracic pressure and prevents air from being sucked into the chest upon removal.
- Withdraw the tube quickly and smoothly.
- Immediately tie the pre-placed suture to close the wound and apply an occlusive dressing.
- Obtain a final chest X-ray to ensure the pneumothorax has not recurred.
References and Further Reading
- British Thoracic Society Guideline for pleural disease Link: https://thorax.bmj.com/content/78/Suppl_3/s1
- How to Place a Chest Tube (Tube Thoracostomy) Source: Behind The Knife (Surgical Education Podcast) Link: https://www.youtube.com/watch?v=7VApcOh6198
- Chest Tubes: A Guide to Monitoring, Troubleshooting, and Removal Source: RegisteredNurseRN Link: https://www.registerednursern.com/chest-tubes-nclex-review-drainage-system/
Dr. Kunal Varma Bheecarry, MD is a GMC registered substantive Consultant Physician in the UK, specializing in Internal Medicine. With more than 15 years of experience on the clinical frontlines in both General Internal Medicine and Acute Medicine, he is passionate about translating complex medical topics, common problems and clinical guidelines into clear, actionable knowledge for healthcare professionals and patients alike. Every article is written and rigorously reviewed by him and other registered medical professionals to ensure clinical accuracy, guideline compliance, evidence-based reliability, authoritativeness and trustworthiness.
Disclaimer: All content is purely educational and does not constitute personal medical advice. It is not a substitute for professional clinical advice and readers must consult their own primary team. All views and interpretations are mine and not related to the work place.