Insertion of a chest tube into the pleural space.

Indications include removal of air or fluid from the pleural space, and administration of scalloping pleural agents.

Contraindications include a bleeding diathesis.

Prior to placement confirmation of a pleural abnormality must be made and may include a chest x-ray, lateral decubitus film, CT of the chest or ultrasound imagery.

Site of placement is selected by physical examination and may indicate findings of decreased breath sounds, on auscultation, dullness to percussion and loss of tectile fremitus in the presence of pleural effusion and hyp2242esonance and decreased breath sounds with pneumothorax.

Chest tubs are usually placed in the fourth-sixth rib interspaces between the middle and anterior axillary lines.

The second interspace in the midclavicluar line can be utilized for drainage of pneumothoraces.

In the presence of loculated fluid or air collections tube placement may require ultrasound or fluoroscopic imaging for optimal placement of a chest tube.

The two most common techniques for tube placement include surgical and guidewire methods.

Loculated fluid can be drained best by guidewire method with visualization using ultrasound, fluoroscopy, or CT.

For thick fluid collections, emphysemas, hemothoraces, bronchopleural fistulas require placement of larger tubes by surgical approach.

Patient typically in a semirecumbent position with the head and shoulder about 30degrees off the bed and the ipsilateral arm is placed above the head to expose the axilla and increase the distance between the ribs.

Anesthesia is usually provided locally, but can be augmented with intravenous narcotics.

Most common drainage systems is the three bottle system, which is commonly incorporated into one container.

The first bottle or column of the drainage system is a drainage repository, collecting fluid from the pleural space.

The second column of the drainage system serves as a water seal, preventing retrograde air entry into the pleural space.

The third column in the drainage system allows adjustment of negative pressure to be applied to the pleural space.

Removal of the chest tube occurs for a pneumothorax when the air leak is resolved and when pleural fluid drainage for pleural effusion is down to 100-150 cc daily.

Techniques or pulling the tube include utilizing end-inspiration, end-expiration, tube clamping, utilizing a water seal or keeping suction on prior to removal.

Complications of the procedure include wrongful placement of the tube, nonfunctional tube, lung laceration, site infections, intercostal vessel injury, intraabdominal placement and tube leakage.

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