INTRODUCTION OF CHEST DRAINAGE TUBES
Placement of an intercostal tube or catheter for pneumothorax can be readily accomplished under local anesthesia, with or without an intercostal nerve block. Chest tube placement may be done at the bedside, but strict aseptic precautions should be observed. The second or third anterior intercostal space in the midclavicular line or the fourth or ﬁfth intercostal space in the midaxillary line are the preferred sites for chest tube placement. To help select the optimal point of entry, chest radiographs should be reviewed unless the clinical situation is one of extreme urgency.
Anteriorly placed chest tubes in the second and third intercostal space must be placed at least two ﬁnger-breadths lateral to the sternal border to avoid injury to the internal mammary vessels. Lateral tube placements must not be made too low in case there is penetration of the sloping diaphragmatic attachment where it joins the chest wall. The act of tube insertion should not be forceful but done with deliberate tactile control to avoid injuring the diaphragm or an enlarged heart if placed on the left side. Pleural access should always be on the superior surface of the rib to avoid the neurovascular bundle.
During the process of local anesthesia, needle aspiration and ready withdrawal of air or ﬂuid should precede any tube insertion. Failure to ﬁnd a free pleural space necessitates choosing another site for tube insertion. Because the parietal pleura can be quite sensitive, adequate local anesthesia is essential. The use of ultrasonography to select an appropriate insertion site has revolutionized pleural access. The site for tube insertion should be one that is away from adherent lung. Tubes placed to drain ﬂuid should be directed posteriorly, but they should be directed anteriorly when placed to drain air.
Multifenestrated tubes should be checked carefully to be sure that all openings lie well within the pleural space. Thoracostomy tubes should be sutured to the skin, but such suture ﬁxation cannot be depended on to hold the tube securely in place; for this purpose, careful binding with adhesive tape is required. All connections of the tube to the drainage system should be secured as well, and care should be taken to protect against traction and tube angulation.
An underwater seal is attached to the tube and tube patency is present if an oscillating column within the tube is observed. Having the patient cough or sniff is the best way to demonstrate small oscillations of tube ﬂuid; barely detectable tube ﬂuid oscillation signiﬁes either full lung expansion or tube blockage. Exacerbation of subcutaneous emphysema or an increasing pneumothorax with a tube in place usually signiﬁes tube blockage or improper placement. Depending on the clinical situation, suction may also be applied to the tube.
After an intercostal tube has been inserted, its position and effectiveness must be checked by radiography as soon as possible.
Smaller tubes (8-14 Fr) can be used to drain pneumothoraces and simple pleural effusions. Larger tubes (>14 Fr) are typically required to drain empyema or hemothoraxes.