Percutaneous Chest Tube

1. Perform timeout to ensure correct patient, procedure, and location. 
2. Insertion site is prepped with chlorhexidine swab x3. Let skin dry.
3. Have a pleur-evac ready with water inserted into water seal chamber to fill line. 
4. Open up chest tube tray + set up sterile field.
5. Put on sterile gown + gloves. 
6. Have assistant help with: 
   1. Opening chest tube kit with chest drain (allowing you to place onto sterile field). 
   2. Emptying lidocaine 20ml of 1% without epinephrine into basin on the sterile field.  
7. Ensure guidewire is prepared and ready to use. Ensure catheter has straightener in place and is ready to use. Ensure dilators + scalpel easily accessible. 
8. Apply drapes + full body gown to patient centered around chest tube insertion site. 
9. Draw up 20mL of lidocaine into syringe. Inject lidocaine into subcutaneous space.
   1. Then inject deeper along the tract of eventual needle insertion. As advance needle, aspirate back to ensure not in a vessel. Continue until at pleural space.
   2. Note: For a pneumothorax, chest tube will eventually be angled superiorly, for fluid angle the tube posterior and inferior, unless the fluid pocket is loculated. 
10. Wait 3 minutes for lidocaine to take effect.

1. Attach insertion needle to a 10cc syringe, anchor non dominant hand onto patient thorax, then insert needle (with dominant hand) into pleural space, steadying needle with non-dominant hand. 
   1. Ensure needle travels just above rib (to avoid the neurovascular bundle). 
   2. Ensure needle trajectory is the same angle as initial ultrasound probe. 
   3. Ensure needle trajectory roughly matches area of anesthesia.
   4. Ensure you are pulling back on syringe while needle is inserted. 
2. Once in the pleural space fluid will flow into the syringe. 
   1. To ensure full needle tip is fully in pleural space (not just the edge of the bevel), advance slightly while withdrawing on syringe. Ensure that there is easy fluid flow back into the syringe. 
3. Carefully twist off the syringe and thread the guidewire into pleural space. 
   1. The guidewire should thread easily and without resistance.
   2. If resistance is felt, stop and reassess needle location. Never force a guidewire.
4. Remove the needle carefully off the guidewire.
5. Scalpel incision over the guidewire to dissect skin and assist with dilation. Size of the incision will depend on the size of the chest tube being inserted. 

1. Dilate over the guidewire with smallest dilator first, holding guidewire at all times. 
2. Dilate with second larger dilator (only as deep as needed to cross chest wall as estimated by ultrasound). 
   1. Should feel a pop once in the pleural space, then remove dilator. 
   2. Note: keep one hand on guidewire at all times and ensure the dilator is moving over the guidewire. Avoid pushing the guidewire into the space with the dilator. 
3. Insert the chest tube over the guidewire, having one hand on guidewire at all times. Advance chest tube to hub or desired length. 
   1. Twist off white cap + remove wire with the white cap + remove straightener. 
   2. Chest tube kept in place and covered with finger. Attach to vinyl connecting tube.
4. Have assistant remove cap from the pleur-evac tubing.
5. Attach connecting tube to connector to pleur-evac. Secure tightly.

1. Take 1 large bite through skin on one side of chest tube 1cm away from the insertion site. Have equal length of string on either side incision. Cut off suture needle. 
   1. Perform hand ties x 3, creating an air knot (so not sinching down on skin).
   2. Wrap the suture strings in opposite directions around the tube (ensure sutures are close together). Then hand tie the suture down to the chest tube. Repeat 3-5 loops.
   3. Repeat step #1 also on opposite side of the chest tube.
2. Gather loose ends of suture together + pink tape them down to the chest tube.
3. Use pink tape to secure the connector piece + tubing from pleur-evac. Taping is done in longitudinal orientation. 
4. Jelonet can be applied around tube insertion site.
5. Add chest drain gauze x2 over the chest tube site. 
6. Roll a piece of gauze and place over the chest drain gauze. Lay the chest tube over roll. Apply piece of gauze over top the tube (now tube is facing down to patients’ feet). 
7. Dress the tube/gauze with hypafix tape to chest wall. 
8. Distal to tube insertion site, tape down the tube with hypafix to patient skin (creating a loop/tent, so there is a gap between tube + patient skin). 
9. Connect pleur-evac to suction if needed. 
10. Document procedure in patient chart. Obtain x-ray to confirm placement. 

1. Assess chest tube for drainage amount (Avoid rapid removal of >1–1.5L at once; consider staged drainage in large effusions to reduce risk of re-expansion pulmonary edema). 
2. Assess chest tube for tidaling. 
3. Assess for air leak, bubbling, subcutaneous emphysema. 
4. Assess vital signs and for respiratory distress. 
5. On x-ray:
   1. Pneumothorax removal = tube ideally is more apical + anterior. 
   2. Fluid drainage = tube ideally more posterior + inferior. 
   3. Observe that the last sentinel drainage hole is within the thoracic cavity. 
   4. Ensure tube is not in the interlobar fissure, mediastinum, or lung parenchyma.

Document Written by: Muralie Vignarajah MD

Staff Reviewed by: Dr. Christina Liak (Internal Medicine, Respirology).