NEJM Teaching Pearls (Oct 11, 2007)
Chest-Tube Insertion: Anatomical Location
Position the patient in either a supine or a semirecumbent position. Maximally abduct the ipsilateral arm or place it behind the patient's head. The area for insertion is approximated by the fourth to sixth intercostals 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 axilla, and a line above the horizontal level of the nipple — often referred to as the “triangle of safety.” You can isolate this area by palpating the ipsilateral clavicle, then working downward along the ribcage, counting down the rib spaces. Once the fourth to sixth intercostals space is felt, move your hand laterally toward the anterior axillary line. This is the area for incision; the actual insertion site should be one intercostals space above the chest-tube insertion.
The most important complications associated with chest-tube insertion include bleeding and hemothorax due to intercostal artery perforation, perforation of visceral organs (lung, heart, diaphragm, or intraabdominal organs), perforation of major vascular structures as the aorta or subclavian vessels, subcutaneous emphysema, reexpansion pulmonary edema, infection of the drainage site, pneumonia, empyema, and intercostal neuralgia. There may be technical problems such as intermittent tube blockage from clotted blood, pus, or debris, or incorrect positioning of the tube, which causes ineffective drainage.
What is the major concern when removing a chest tube?
The major concern with removal of a chest tube is the risk of pneumothorax during removal. Physician practice differs with respect to the point in the respiratory cycle at which the tube is removed: during end-inspiration or end-expiration. Neither has been shown to be superior in the prevention of pneumothorax. When preparing to remove the tube, two people may need to participate so that one can instruct the spontaneously breathing patient and pull the tube while the other can quickly occlude the insertion site.
What factors dictate what size chest tube to insert in a patient?
The size of the chest tube that is needed depends on the indication for the insertion of a chest tube. For a large pneumothorax in a patient in stable condition, a 16- to 22-French chest tube should be used with the open technique (a 14-French or smaller for Seldinger method). For a large pneumothorax in an unstable patient or a patient receiving mechanical ventilation, a 24- to 28-French chest tube catheter should be used. A smaller chest tube, 8- to 16-French can be used for a malignant or transudative pleural effusion.
From: N Engl J Med 357;15 http://www.nejm.org/ october 11, 2007.