Chest Tube Placement Guideline

Pre-Procedure Considerations

The American Thoracic Society recommends using blunt dissection technique over trocar insertion to minimize risk of organ injury and complications, with a strong recommendation for proper anatomical positioning within the "safe triangle" 1
Contraindications for chest tube insertion include coagulopathy, adhesions between the chest wall and lung, and skin infection at the insertion site, emphasizing the need for careful patient selection and pre-procedure evaluation 1

The European Respiratory Society suggests that the optimal placement area is within the "safe triangle" which includes the lateral border of pectoralis major muscle, anterior border of latissimus dorsi muscle, and a line superior to the horizontal level of the nipple, to minimize risk of injury to vital structures 1
Proper technique involves positioning the patient appropriately, identifying and marking the insertion site, administering adequate local anesthesia, making an incision parallel to the rib, performing blunt dissection through the chest wall, and entering the pleural space just above the rib, with a complication rate that should not exceed 3% when properly placed 1
The Seldinger technique is recommended for small-bore chest tubes (10-14F), involving a guidewire and dilator to minimize complications, with a focus on proper analgesia and patient positioning 1
For larger tubes, blunt dissection is preferred, with careful attention to anatomical landmarks and the "safe triangle" to reduce the risk of organ injury, as outlined in the British Thoracic Society and American Thoracic Society guidelines 1

For pneumothorax, the tube should be directed apically, while for fluid collections, the tube should be directed posteriorly and inferiorly, with the use of ultrasound guidance strongly recommended for marking the optimal insertion site, especially for pleural effusions, to reduce risk of complications and improve placement accuracy 1
The following table summarizes the recommendations for chest drain insertion:

Indication	Drain Size	Technique	Imaging Guidance
Pleural effusion	10-14F	Seldinger	Ultrasound
Malignant effusion	10-14F	Seldinger	Ultrasound
Loculated collection	10-14F	Seldinger	Ultrasound
Large effusion	10-14F	Seldinger	Ultrasound

Common complications include organ injury, intercostal vessel injury, tube malposition, and infection, which can be minimized by using blunt dissection, avoiding substantial force during insertion, maintaining strict aseptic technique, ensuring proper anatomical positioning, and using ultrasound guidance when available, with the use of blunt dissection technique strongly recommended to minimize risk of organ injury and complications, as supported by the citation 1
Immediate complications of chest tube insertion include organ injury, intercostal vessel injury, pain, and subcutaneous emphysema, requiring prompt recognition and management 1
Delayed complications include infection, tube blockage, accidental dislodgment, and re-expansion pulmonary edema, emphasizing the need for ongoing monitoring and patient education 1

The chest tube should be connected to an underwater seal drainage system, kept below chest level, and monitored for air leaks and drainage, with a post-procedure chest radiograph obtained to confirm position, as part of the standard care for patients with chest tubes 1
The drainage system should be kept below chest level, with regular monitoring for air leaks, drainage amount and characteristics, and vital signs, to ensure optimal patient outcomes and minimize complications 1
The chest drain should be removed when there is no air leak for 24 hours, drainage is less than 300 mL/day, and clinical and radiographic improvement is observed, as recommended by the British Thoracic Society and American Thoracic Society guidelines 1

Pediatric patients require age-appropriate tube sizes, consideration of sedation in addition to local anesthesia, and more vigilant monitoring for respiratory compromise, with attention to potential complications such as re-expansion pulmonary edema, as per American Thoracic Society guidelines 2
Patients with tracheostomy require special attention to ventilation during the procedure and consideration of positioning to optimize both tracheostomy and chest tube function, with careful monitoring for complications such as respiratory compromise 3
Indwelling pleural catheters may be considered for patients with trapped lung, recurrent effusions after failed pleurodesis, or limited life expectancy, as per UK guidelines 4
Early involvement of a respiratory specialist or thoracic surgeon is recommended for patients with pleural effusions, and intrapleural fibrinolytics may be considered for loculated collections, with a strength of evidence supporting the use of intrapleural fibrinolytics in selected cases 5, 6

Avoiding routine chest drain insertion for all pleural effusions, using small-bore catheters, and avoiding substantial force during insertion can prevent unnecessary complications and organ injury, with a strength of evidence supporting the use of small-bore catheters and careful insertion techniques 4, 6
Never clamping a bubbling chest drain, avoiding rapid drainage of large effusions, and avoiding placement of drains without imaging guidance can also prevent complications, as per British Thoracic Society guidelines 6, 5
During the COVID-19 pandemic, consider chest tube insertion as an aerosol-generating procedure, using appropriate PPE (Level 2) and taking extra precautions to avoid open communication with the pleural space, as recommended by the American Thoracic Society and the British Thoracic Society 7, 6, 5