Tricks of the Trade for Inserting a Surgical Chest Tube

Below are some simple tips and tricks to ensure successful and safe placement of surgical chest tubes.  Full disclosure, these are tips and tricks I learned by trial and error and through word of mouth, and they have not been formally studied or peer reviewed.

1. Double Glove

Placing a surgical chest tube is an inherently dangerous procedure that requires inserting your finger into the patient’s chest wall.  This procedure is usually indicated due to the sequelae of broken ribs. Even if all the correct procedural steps are followed, the person placing the chest tube risks puncturing themselves on a broken rib.  Wearing two pairs of sterile gloves may just be enough additional protection to spare you a month of post-exposure prophylactic medications and significant mental stress from a finger stick.

2. Prep and drape a large area

When applying Betadine, prep out a much larger area than you initially think you would need.  Prep the skin in a sterile manner from the sternum to the posterior axillary line and from the 12^th rib to the axilla.  This way when you lay out your blue sterile towels or drapes, you can leave a large area of skin visible in the sterile field including your landmarks for appropriate tube placement.  You should drape so the nipple, infra-mammary line, base of the axilla, and lateral edge of the latissimus dorsi are visible.

3. Tap the rib with a closed Kelly clamp prior to puncturing the pleural space

After you have made your incision over the 4^th or 5^th intercostal space, you bluntly dissect through the fat and subcutaneous tissue with a Kelly or your finger until your reach the ribs and intercostal muscles. At this point, it is critically important to find where the ribs are to ensure when you pop through the intercostal tissue into the pleural space with your Kelly, you are inserting it just above the rib and away from the neurovascular bundle that runs just inferiorly to each rib.   When using the Kelly or your finger blindly, it is often difficult to identify the difference between the ribs and muscle especially when there is still some fat adhered to them. Using the Kelly clamp to gently tap along the ribs and muscle layer makes it much easier to identify the ribs and the optimal location for insertion.

4. Use a finger to guide the chest tube toward the apex of the chest cavity and twist the tube as you insert it

Try to keep a finger inserted in the pleural space, parallel to the Kelly and chest tube, as you insert the chest tube and remove the Kelly. Keep the finger in place and use it to point the tube along the back wall and toward the apex.  Twisting the tube freely 360 degrees also helps ensure the tube does not go into the fissure between the lobes of the lung.

5. Do not insert the tube too far!

Over eager doctors are often tempted to advance the chest tube as far as possible into the chest cavity.  The centimeter markings on the tube itself are often ignored or misunderstood.  The ideal depth for the chest tube ensures the sentinel hole is inside the pleural space without advancing too much further than that.  It is important to realize that the measurements on the tube start at the sentinel hole (0 cm is just distal to the sentinel hole), not the very end of the tube! There is often approximately 8 cm of tube (the part with the holes in it) that are not included in the measurements.  So when you suture a tube in place at 10 cm, in fact 18 cm of plastic are inside the patient.  For most patients, 10 cm is an adequate and safe depth of insertion.  Very large people may require 12-14 cm.  Insertion beyond these depths risks injury to the lung, cardiac, and mediastinal structures, especially if you were unsuccessful at guiding the tube toward the apex (see #4).

Below is an example of what can go wrong if tips 4 and 5 are ignored. Luckily, this chest tube missed any major structures, and the patient was not harmed. (#notmytube)

6. Lastly, dent the plastic when you suture the tube in place

Once you have finally gotten that darn tube inserted to the correct depth and in a good position without hurting yourself or the patient, you want to secure it in place.  A good rule of thumb to ensure your knots around the tube are secure is to tie them tight enough to create a small indent in the plastic tube.  Just don’t tie it so tight that you close off the entire tube!