• Primary Spontaneous Pneumothorax (patient without underlying lung disease)
    • Unstable Patients (RR >24 breaths/min, HR <60 bpm or >120 bpm, abnormal BP, room air 02 sat <90%, or cannot speak in full sentences)
    • Large Pneumothoraces (>3 cm Apex-to-Cupola Distance)
  • Secondary Spontaneous Pneumothorax (patient with underlying lung disease or pleural disease)
    • Stable Patients (RR <24 breaths/min, HR >60 or <120 bpm, normal BP, room air O2 sat >90%, and can speak in full sentences)
    • Unstable Patients (RR >24 breaths/min, HR <60 bpm or >120 bpm, abnormal BP, room air 02 sat <90%, or cannot speak in full sentences)
    • Large Pneumothoraces (>3 cm Apex-to-Cupola Distance)
  • Overt Traumatic Pneumothorax (diagnosed clinically or by CXR)
  • Hemothorax
  • Empyema


Triangle of Safety -

Triangle of Safety -

  • Obtain Informed Consent if able including a discussion with the patient about potential complications of the procedure
  • Dress – Mask, eye shield, gown, sterile gloves, headwear
  • Position Patient
    • Head of bed 30 to 45 degrees
    • Secure the arm on the affected side out of the field
  • Identify Site of Procedure
    • “Triangle of safety” - Lateral edge of the pectoralis major, mid-axillary line, and above the 5th intercostal space (nipple line in males, inframammary crease in females)
  • Place patient on nasal oxygen
  • Antibiotics - Give one dose of intravenous cefazolin x 1 gram (Alternative: Clindamycin 600 IV) 
  • Pain control and sedation for patient
    • Fentanyl, Morphine, Dilaudid, or Ketamine (in analgesic dosing)
    • Consider procedural sedation with Ketamine

Tube InsertioN

NEJM Tube Thoracostomy Video (Institutional Subscription Required)

NEJM Tube Thoracostomy Video (Institutional Subscription Required)

  • Clean the insertion site with chlorhexidine or iodine.
  • Create a sterile field by draping four sterile towels and a large sterile drape to frame the insertion site.
  • Maintain sterile field throughout the procedure.
  • Prepare the chest tube by cutting the external end to fit onto the atrium tubing and clamp it with Kellys.
  • Anesthetize the skin and subcutaneous tissue. Too little anesthesia is the most common mistake.
    • Start with the skin and subcutaneous tissue using lidocaine 1% with epinephrine.
    • Advance the needle until it hits the rib inferior of the selected intercostal space and inject anesthetic over the periosteum. Then inject over the superior rib in a similar manner.
    • While continuously aspirating, advance the needle over the inferior rib and into the pleural space (evidenced by return of air). Withdraw the needle until the return of air ceases and inject onto the parietal pleura.
  • Make a superficial skin incision parallel to and overlying the rib inferior to the selected intercostal space.
  • Create a subcutaneous track using Kelly clamps for blunt dissection.
  • Keeping the Kellys in the closed position, advance over the inferior rib until the pleura is breached (confirm with “pop”/loss of resistance), then open the Kellys and withdraw them to create a tract.
  • Insert one finger into the pleural space to confirm intrapleural location and rotate to identify lung and break up adhesions.
  • Advance the chest tube into the pleural space using Kellys to guide it into appropriate position, superior for pneumothorax and inferior for hemothorax.
  • Remove the Kellys and advance the chest tube to the appropriate depth.
  • Confirm with chest radiograph before securing. 

Securing the Tube

  • Close with simple suture across incision, close to tube
  • Wrap remaining suture around tube to anchor
  • Leave ends long, wrap around tube and leave in a bow (to be used to close skin after tube removal)
  • Occlusive dressing
    • Cut a Y-cut into stack of 4x4 gauze ~2-3 layers thick
    • Apply bacitracin/petroleum on one side of the gauze
    • Place petroleum impregnated gauze around the thorocostomy tube with the petroleum against to the incision
    • Apply 2-3, 4” by 8” tegaderm pieces over occlusive dressing to hold it in place

Dr. Omedary - Surgical Knot Tying:Drain Stitch. In this video I show you how to tie an easy drain stitch. Refer to my other videos for help with one and two-handed ties.

Emergency Trauma Management - How to Secure Your Intercostal Catheter/Chest Tube


  • Kirsch, T. Tube Thoracostomy. Roberts and Hedges Clinical Procedures in Emergency Medicine. Ch. 10. 175-196.
  • Gonzales RP and Holevar MR: Role of prophylactic antibiotics for tube Thoracostomy in chest trauma, Am Surg 1998, 64:617-620. 

Comments? Questions? Suggestions for Improvement? Send them Our Way!

Name *