Tube thoracostomy

  1. Identify indications for chest tube
  2. Provide sedation/anxiolysis/analgesia as appropriate
  3. Appropriately position the patient (ipsilateral arm up)
  4. Prepare the chest wall and places sterile drapes
  5. Identify landmarks (triangle of safety is the border of the pectoralis anteriorly, latissimus dorsi posteriorly, nipple line or infra-mammary fold inferiorly)
  6. Prepare equipment (2 clamps on chest tube)
  7. Identify insertion site (within the triangle of safety, anterior axillary line, in 5th intercostal space)
  8. Inject local anesthesia; infiltrates both superficial and deep tissues
  9. Incise chest wall at appropriate location, size, and depth
  10. Grossly dissect chest wall with clamp until pleural cavity entered (braces clamp with non-dominant hand to prevent over-insertion)
  11. Open clamp and withdraw it while open to dilate pleura
  12. Feel for lung as appropriate, keep finger in tract
  13. Advance chest tube at appropriate angle and depth (directed toward apex of lung, estimate distance based on exterior landmarks)
  14. Attach chest tube to chamber and vacuum
  15. Secure chest tube to chest wall skin using hand-tie technique (“Roman sandal”)
  16. Apply occlusive dressing
  17. Secure remainder of tube (mesentery tape and tapes connection)
  18. Order appropriate chest X-ray to confirm placement