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Chest Tubes – What You Need to Know

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Written by Alex Clark

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Pleural cavity decompression via surgical tube thoracostomy or pleural catheter (pigtail) is a core EM skill. This excellent, high-yield review gets you ready.

Totally tubular, dude

Indications & Contraindications

  • Indications: Pneumothorax, PTX (spontaneous/traumatic), hemothorax, pleural effusion.
  • Relative contraindications: Overlying cellulitis, coagulopathy (INR >1.5—but do not delay if emergent), or complex anatomy (adhesions, blebs—consider CT before and/or cautious finger sweep during).
  • No absolute contraindications.

Thoracostomy Options

  • Tube sizes: Small (7–14 Fr), Medium (16–22 Fr), Large (>24 Fr).
  • Tension PTX = emergent decompression:
    • Needle the 4th/5th intercostal space (ICS), anterior axillary line or do finger thoracostomy (my preferred), then definitive tube or pleural catheter.
  • Pleural catheters (aka pigtails): Seldinger-based, pigtail-type catheters; less invasive, lower pain, shorter duration, possibly slower drainage.
  • Size selection:
    • Primary (spontaneous) and traumatic PTX: Small-bore = large-bore efficacy, with fewer tube days.
    • Traumatic HTX: Recent studies support ≤14 Fr equivalence to 28–32 Fr; ATLS still recommends larger—follow local policy.
    • Large tubes may reduce risk of obstruction if: recurrent PTX, bronchopleural fistulas, or complex effusions/adhesions.

Procedure Preparation

  • Location: Triangle of safety (above 5th ICS, anterior/mid-axillary line, superior rib border). For apical PTX, pleural catheter at 2nd ICS midclavicular line may be considered.
  • Ultrasound: Confirm diaphragm, map intercostal artery (color Doppler), identify lung point or effusion, confirm intrathoracic entry.
  • Positioning & setup: Supine, semi-recumbent 45°, ipsilateral arm flexed/abducted; generous local anesthesia ± regional block and/or procedural sedation; ensure equipment and drainage system ready pre-insertion.

Surgical Thoracostomy Technique

  • See Table 1 for summarized steps.
  • Pearls:
    • 360° finger sweep before tube insertion.
    • If tube resists prior to last fenestration, it’s likely in a fissure or parenchyma—withdraw slightly, rotate, and re-insert.
    • To assess kinking: rotate tube 180°—if it springs back, it’s kinked.
    • For patients with excess soft tissue, modified Seldinger technique with bougie may facilitate entry.
    • Direct tube posterior-superiorly to optimize air/fluid evacuation.

Pleural Catheter Technique

  • See Table 2 for summarized steps.
  • Seldinger Technique: aspirate air/fluid → wire → incision → dilator/introducer → catheter advanced until all fenestrations within pleural space.
  • Attach 3-way stopcock and suction, secure without occluding tube lumen, apply occlusive dressing.

Thoracostomy Tube Drainage Systems

  • Types: Three-chamber (collection, water seal, suction) or one-way Heimlich valve (ambulatory PTX).
  • Troubleshooting:
    • Continuous bubbling = air leak.
    • Absent tidaling (vertical fluid movement with respiration) = lung re-expanded or tube obstructed.
    • Keep system upright and below chest level.
  • Gravity vs. suction: Gravity (water-seal) often sufficient for pleural drainage after initial suction; continue suction for persistent air leak (although in my experience may paradoxically worsen in bronchopleural fistula) or for heavy effusion burden.

Complications (Full list in Table 3)

  • Tube malposition: Most common. Leave if draining; replace if external or nonfunctional.
  • Nonfunctioning tube: Check for obstruction or suction failure; avoid milking/stripping.
  • Serious complications: Intercostal bleed, pulmonary laceration/infarction, or injury to mediastinal/extra-thoracic structures → surgical consult.
  • Re-expansion pulmonary edema: Avoid >1L rapid effusion drainage (although RPE may be more related to increased negative pressure & trapped lung; watch for chest pain during); treat hypoxemic respiratory failure with NIPPV.
  • Infection prevention: Single-dose cefazolin/ceftriaxone for trauma may reduce empyema/pneumonia risk.

How does this change my practice?
The authors provide a comprehensive overview of all things thoracostomy. I highly recommend taking 30 minutes to read the full article.

Practice-ready takeaways…

  1. Unstable/Tension? Finger thoracostomy (+ surgical tube)
  2. Bigger (surgical tube) is better? Only in complex parenchymal disease (bullae & adhesions), recurrent effusion/PTX, suspected empyema w/ sonographic complexity
  3. Everything else? Pleural catheter (≤14 Fr) 
  4. Apical PTX on mechanical ventilation? Don’t forget midclavicular line, 2nd ICS approach
  5. Subcutaneous tissue in your way? Next time try the bougie

Source
Tube Thoracostomy and Pleural Catheters: A Review for Emergency Clinicians. J Emerg Med. 2025 Oct;77:100-116. doi: 10.1016/j.jemermed.2025.07.053. Epub 2025 Aug 5. PMID: 40896901.

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