Chest tube insertion: Procedure, complications, and removal
Doctors may need to use a chest tube for many purposes, such as inflating a collapsed lung, draining fluid or blood, or delivering medications.
This article explains how chest tubes work, what to expect during the insertion procedure, and the possible complications.
Diagram of a chest tube draining fluid from a plural effusion.
Doctors insert chest tubes for a variety of conditions, including:
- Empyema: An empyema is an infection that develops in the pleural space.
- Hemothorax: Hemothorax occurs when excess blood builds up in the chest cavity, usually due to an injury, tumor, or bleeding disorder. Doctors may also insert a chest tube to prevent hemothorax after chest surgery.
- Pleural effusion: A pleural effusion is a buildup of fluid in the pleural space. It can occur due to heart failure, lymphatic fluid, a lung tumor, or infections such as tuberculosis and pneumonia.
- Pneumothorax: A pneumothorax is a collapsed lung. Sometimes a lung can collapse without warning, which is known as spontaneous pneumothorax. A pneumothorax can also occur as a result of a chest injury, such as a gunshot or stab wound.
A doctor may also insert a chest tube to perform a procedure known as pleurodesis.
Pleurodesis uses a chest tube to deliver chemicals into the pleural space. These chemicals irritate the lining of the lung and cause intentional scarring, which keeps fluid from building up in this area.
A doctor will often connect the chest tube to a container that holds the drained fluid. It is possible to hook the container up to a suction device to remove fluid or blood more effectively.
Chest tubes come in several sizes. Manufacturers use a French catheter scale, abbreviated as Fr, to classify the tubes according to their internal diameter. One Fr is one-third of a millimeter and chest tubes are available in sizes ranging from 6–40 Fr.
Doctors can use straight tubes or pigtail tubes, which coil at the end. They will select the size of chest tube that suits the individual's anatomy and the procedure.
Chest tubes look like very large, plastic straws. They have three main areas:
- The tip, which contains drainage holes.
- The body, which has markings that indicate how far a doctor has inserted the tube.
- The tail, or end, which tapers slightly for connection to a suction or drainage system.
Generally, chest tubes divide into two size varieties: large-bore and small-bore.
A large-bore chest tube is 20 Fr or larger, while a small-bore chest tube is smaller than 20 Fr.
Smaller tubes are also available and are known as pleural catheters. Doctors will often tunnel them in a vein or carefully place them under the skin of the chest for long-term use.
A pleural catheter may be necessary for a person who has a continual buildup of pleural fluid due to chronic infection, cancer, or liver disease.
A doctor will use a local anesthetic to numb the area before a chest tube insertion.
A doctor may put a person under general anesthesia for a chest tube insertion. Alternatively, they will use a local anesthetic to numb the area before inserting the tube and will also provide the person with sedation and pain medications.
There are different incision approaches for inserting the chest tube, but the procedure will follow the same essential steps:
- Elevating the head of a person's bed by 30–60 degrees. Someone will usually raise the arm on the affected side above the head.
- Identifying the tube insertion site. This will typically be between the fourth and fifth ribs or between the fifth and sixth ribs, just behind the pectoralis (chest) muscle.
- Cleaning the skin with a solution, such as povidone-iodine or chlorhexidine. Doctors will allow the skin to dry before placing a sterile drape over the patient.
- Using local anesthetic to numb the insertion site. Once the area is completely numb, a doctor may insert a needle more deeply to see if they can pull back fluid or air. This will confirm that they are in the right area.
- Making an incision of about 2–3 centimeters (cm) through the skin. Using a surgical instrument called a Kelly clamp, the doctor will widen the incision and gain access to the pleural space. The clamp insertion should be slow to avoid puncturing the lung.
- Inserting a gloved finger into the incision site. This is to confirm that the area is the pleural space. The doctor will also feel for unexpected findings, such as a mass or scar tissue.
- Inserting the chest tube through the incision site. If fluid begins to drain through the tube, it is in the right place. It is also possible to attach the tube to a chamber containing water that moves when a person breathes. If this does not occur, the tube may need repositioning.
- Suturing the tube in place so that the seal is as airtight as possible.
- Covering the tube insertion site with gauze pads.
A chest X-ray can also help to confirm the tube's placement.
During a chest tube insertion, the doctor must work around several major organs, including the lungs and heart.
Potential complications include:
- cardiac shock, if the tube punctures an area of the heart
- excessive bleeding
- injuries to the heart, blood vessels, arteries, or lungs
- perforation (puncturing) of the diaphragm
- punctured lung
A doctor should carefully explain these risks to the individual before the procedure.
Ideally, they will avoid putting a chest tube in someone who is taking blood thinners due to the risk of bleeding. However, inserting the chest tube can sometimes be a life-saving, emergency procedure.
Chest tube removal
Doctors remove chest tubes when they are no longer necessary, for example when the tube is no longer draining blood or fluid.
They will also remove the tube if it becomes blocked or is not working correctly.
According to the Chest Foundation, most people need to keep the chest tube in for a few days. When removing a chest tube, a doctor will cut the sutures holding the tube in place and gently pull it out. The procedure can be uncomfortable, but should not be painful.
Ideally, a person's symptoms will improve following the use of a chest tube.
People should monitor the incision site for signs of infection while it heals, and inform their doctor as soon as possible if the wound swells, turns red, or starts oozing pus. It is likely that a small scar will remain at the insertion site.
A chest tube can be a relatively non-invasive way to access the pleural space to drain fluid or administer medication.
Sometimes, if the chest tube does not resolve a person's problem, they may need more invasive surgery.
After chest tube removal, a person should follow a doctor's recommendations on how to care for the incision site.