Chest Tube Insertion Guidelines

Pre-Insertion Preparation

Small-bore chest tubes (8-12 FG) should be used whenever possible to minimize patient discomfort, as there is no evidence that large bore chest drains confer any advantage 1, 2
The British Thoracic Society recommends gathering all necessary equipment, including sterile gloves, gown, chest tube of appropriate size, sterile towels, betadine or chlorhexidine for skin cleansing, local anesthetic, suture material, and chest drainage system 1, 2
Position the patient appropriately, with cooperative patients under local anesthesia slightly rotated with arm on affected side behind head to expose axillary area 1, 2
Alternative positions include upright leaning over a table with a pillow, or lateral decubitus position 1, 2
Use sterile technique throughout the procedure to avoid wound site infection or secondary empyema 1, 2
Clean a large area of skin with betadine or chlorhexidine 1, 2

Identify insertion site, typically in the "safe triangle" - bordered by anterior border of latissimus dorsi, lateral border of pectoralis major, and a line horizontal to the nipple 3
Administer local anesthesia by injecting at the insertion site and down to the pleura 3
Make incision, creating a small incision at the predetermined site, large enough to accommodate the chest tube 3
Never use substantial force or a trocar during insertion, as this risks sudden chest penetration and damage to intrathoracic structures 1, 2
Secure the tube by closing the incision with a non-absorbable suture around the chest tube, and apply a stay suture through the skin and criss-cross up the drain 1, 2
Apply sterile dressing around the insertion site 1, 2
Confirm placement by obtaining a chest radiograph to confirm proper tube position and to ensure a pneumothorax has not developed 1, 2
Look for equal bilateral chest wall expansion with ventilation 4, 5

Record the depth of tube insertion prominently in the patient's chart 4, 5, 6
Never clamp a bubbling chest tube, as this may convert a simple pneumothorax into a tension pneumothorax 3
Consider inserting a nasogastric tube after chest tube placement if the patient requires mechanical ventilation, as recommended by the Society of Critical Care Medicine 7, 8

Using excessive force during insertion can be avoided by always inserting the tube gently to avoid damage to intrathoracic structures 1, 2
Inadequate securing of the tube can be avoided by ensuring the tube is well-secured to prevent accidental dislodgement 1, 2
Failure to obtain post-procedure imaging can be avoided by always getting a chest radiograph after insertion to confirm proper placement 1, 2