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Chest-Tube Insertion
Shelly P. Dev, M.D., Bartolomeu Nascimiento, Jr., M.D., Carmine Simone, M.D., and Vincent Chien, M.D.
Indications

Insertion of a chest tube is indicated in either emergency or nonemergency situations. Specific indications are listed in Table 1.1-3
ContraindicationsPublished guidelines state that there are no absolute contraindications for drainage by means of a chest tube1 except when a lung is completely adherent to the chest wall throughout the hemithorax.2 Relative contraindications include a risk of bleeding in patients taking anticoagulant medication or in patients with a predisposition to bleeding or abnormal clotting profiles. Whenever possible,coagulopathies and platelet defects should be corrected with the infusion of blood products, such as fresh frozen plasma and platelets.
Equipment

From the Department of Critical Care Med­ icine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto. Address reprint requests to Dr. Dev at the Depart­ ment of Critical Care, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Office D­112,Toronto, ON M4N 3M5, Canada, or shelly.dev@sunnybrook.ca. N Engl J Med 2007;357:e15.
Copyright © 2007 Massachusetts Medical Society.

Most hospitals have presterilized, packaged chest-tube–insertion trays. The key components of the tray are a scalpel with size 11 blade; several dissecting instruments, such as curved Kelly clamps or artery forceps; a 10-ml syringe and a 20-ml syringe; onesmall-gauge needle (size 25) and one larger-gauge needle for deeper anesthetic infiltration (size 18–21); a needle driver; scissors; one packet of strong, nonabsorbable, curved sutures of size 1.0 or larger, made from silk or nylon4; and a chest tube of appropriate size (see below). A commercially available pleural drainage system, such as the Pleur-evac (Teleflex Medical), should also be ready forconnection after the chest tube is inserted.
Table 1. Indications for Chest-Tube Insertion. Emergency Pneumothorax In all patients on mechanical ventilation When pneumothorax is large In a clinically unstable patient For tension pneumothorax after needle decompression When pneumothorax is recurrent or persistent When pneumothorax is secondary to chest trauma When pneumothorax is iatrogenic, if large andclinically significant Hemopneumothorax Esophageal rupture with gastric leak into pleural space Nonemergency Malignant pleural effusion Treatment with sclerosing agents or pleurodesis Recurrent pleural effusion Parapneumonic effusion or empyema Chylothorax Postoperative care (e.g., after coronary bypass, thoracotomy, or lobectomy)

n engl j med 357;15

www.nejm.org

october 11, 2007

e15Downloaded from www.nejm.org on September 5, 2009 . Copyright © 2007 Massachusetts Medical Society. All rights reserved.

The new england journal of medicine

Grasp the proximal free end of the chest tube with a clamp or forceps. Using another clamp or forceps, grasp the distal tip of the tube to prepare it for insertion.4
Chest-Tube Size

The size of the chest tube that is neededdepends on the indication for the insertion of a chest tube. Table 2 provides a summary of size recommendations based on indication.5-11
Preparation

Figure 1. Locating Landmarks.

If time permits, explain the procedure to the patient or next of kin and obtain written consent; this may not be possible when the need for chest-tube insertion is urgent. Position the patient in either a supine or asemirecumbent position. Maximally abduct the ipsilateral arm or place it behind the patient’s head. The area for insertion is approximated by the fourth to fifth intercostal space in the anterior axillary line at the horizontal level of the nipple. This area corresponds to the anterior border of the latissimus dorsi, the lateral border of the pectoralis major muscle, the apex just below the...