1. Chest tube insertion lab

2. Tube placement sites Depends on purpose Anterior (triangle of safety)
Pneumothorax
Low lateral (Ultrasound guidance really helps)
Fluid drainiage

3. Indications

4. Triangle of Safety

5. Incision and Insertion Sites

6. Dissection OVER rib

7. Chest tube size
Air: small
Fluid: medium
Blood: Large
Pus: Large

8. Alternate procedures Underwater seal jar Heimlich valve
Simple needle aspiration and recheck
For simple pneumothorax only:
Small
No tension
Underwater seal jar
Heimlich valve

9. Tube removal criteria Pneumothorax: no bubbling and lung expanded
Consider an interval of tube clamping before removal
Probably best to not remove while on mechanical ventilation, especially with PEEP
Drainage: less than 200 cc/24 hours
Take care to seal hole during and after removal!
Follow-up chest x-ray

10. Complications
Bleeding and hemothorax due to intercostal artery perforation
Perforation of visceral organs (lung, heart, diaphragm, or intra-abdominal organs)
Perforation of major vascular structures such as the aorta or subclavian vessels
Intercostal neuralgia due to trauma of neurovascular bundles,
Subcutaneous emphysema,
Re-expansion pulmonary edema
Infection of the drainage site
Pneumonia, and empyema
Technical problems such as intermittent tube blockage from clotted blood, pus, or debris, or incorrect positioning of the tube, which causes ineffective drainage.