Chest Tube Placement Recommendations

Optimal Location and Size

For left-sided tension pneumothorax, the 2nd intercostal space along the midclavicular line may be safer due to potential risk of cardiac injury at the 5th intercostal space 1

Small-bore chest tubes (14F or smaller) should be used initially for most indications 2, 3
The British Thoracic Society (BTS) guidelines recommend initial drainage of pleural infection using a small-bore chest tube (14F or smaller) 2, 3
There is no evidence that large tubes (20-24F) are better than small tubes (10-14F) in the management of pneumothoraces 4, 5, 6
Small-bore tubes (10-14F) have shown primary success rates of 84-97% in treating pneumothoraces 4
Factors that might necessitate larger tubes include presence of pleural fluid 6, large air leak that exceeds the capacity of smaller tubes 6, and persistent air leak requiring replacement of a small tube with a larger one 4

For central venous catheters, the tip should lie outside the pericardial sac to avoid the risk of pericardial effusion/tamponade 7

Infection including empyema (estimated at 1% after chest tube insertion) 5
To minimize complications, use proper aseptic technique during insertion or manipulation of chest drainage systems 5
Avoid clamping a chest tube that is still bubbling, as this may convert a simple pneumothorax into a tension pneumothorax 6

For tension pneumothorax, a 7 cm needle may be appropriate for decompression at either the 5th intercostal space along the midaxillary line or the 2nd intercostal space along the midclavicular line 1
For electrical impedance tomography monitoring, belt positioning is typically between the 4th and 5th intercostal space in a transverse plane 8