Chest Tube Placement
Updated On: July 23, 2026
Anesthetic Approaches
Tension pneumothorax - respiratory distress with absent breath sounds and distended neck veins is a clinical diagnosis, not a radiological one. Decompress with a needle or catheter first and let the definitive tube follow, because waiting for a film is how these patients arrest.
Conversion under positive pressure - a simple pneumothorax tolerated awake can become a tension pneumothorax once you start bagging, showing as rising airway pressure with falling blood pressure. Drain a known pneumothorax before induction, not after.
Local infiltration alone - most drains go in awake with lidocaine to skin, periosteum and parietal pleura, and the pleura is the layer that actually hurts. A cooperative adult needs explanation and generous local rather than sedation.
Reason for the referral - you are called when the patient is agitated, hypoxic, a small child, or already anesthetized for something else. That means you are managing the instability rather than the drain, and resuscitation comes first.
Ultrasound at the bedside - a pleural scan finds fluid and absent lung sliding faster than a portable film and marks a safe interspace. Expect the machine in the room, and position the patient for the scan as well as for the operator.
Re-expansion pulmonary edema - emptying a large chronic collection quickly can flood the lung that has just re-expanded. Drain in stages, stop for cough or chest tightness, and treat new hypoxia after a big drain as edema until proven otherwise.
Analgesia for the tract - the drain sits between the ribs and moves with every breath, so the pain is pleuritic and worst on coughing, and a patient who will not cough retains sputum. Regular multimodal cover beats intermittent opioid alone.
Sedation in a hypoxic patient - whatever is in the chest is also the reason they will not tolerate apnea, and a bolus of propofol in a breathless trauma patient buys stillness at the cost of the airway. Titrate small, keep them talking, be ready to intubate.
Full stomach - an emergency drain means an unfasted patient, often with a collar on and swallowed blood in the stomach. If the plan becomes a general anesthetic, treat it as a rapid sequence and secure the airway before the chest is opened.
Handover of the drain - say whether it is on suction or underwater seal, whether it is bubbling, and that it stays unclamped in transit, because clamping a bubbling drain rebuilds the tension you just relieved.
Lateral position (general considerations): If an ETT has been placed, make sure ETT is secure with extra tape. Unhook anesthesia circuit while turning lateral and be especially careful to keep patient's head neutral and aligned with body to avoid neck injury. Once lateral, use pillows/blankets/foam headrest to keep the patient's head in neutral position. The most common nerve injury for orthopedic lateral procedures are neurapraxias of the brachial plexus. These are motor and/or sensory loss for 6-8 weeks due to pressure on the contralateral (dependent) axilla. To prevent this, place an axillary roll under the patient (caudad to the axilla, on the rib cage, and NOT in the axilla). Check routinely to make sure the axillary roll does not migrate into the axilla. If the non-dependent arm is placed on a board, check padding and reposition regularly to avoid radial nerve compression. If a bean bag is employed, check the hard edges to ensure that unnecessary pressure isn't being put on soft tissues. Pad all dependent bony prominences such as the fibular head (to prevent peroneal nerve injury), and place pillows between the knees and ankles (to prevent saphenous nerve injury). If anterior hip supports are in place, ensure they are properly padded or neuropraxias and/or occlusions of large blood vessels may result.
Off-site (general considerations): Extra precaution should be taken preoperatively if the surgery is planned off-site (away from the OR or your normal work spaces). Depending on your facility setup, it's wise to take emergency airway equipment and drugs with you that would be necessary to treat the gamut of anesthesia emergencies.
Air, blood or pus in the pleural space separates lung from chest wall, and the lung collapses along its own elastic recoil. A chest tube drains the collection and restores apposition, with an underwater seal acting as a one-way valve so air leaves the chest but cannot return. Tension develops when the tear itself behaves as a valve in the opposite direction: air enters on every breath and cannot escape, intrapleural pressure climbs, the mediastinum shifts and venous return to the right heart falls. The patient then becomes hypotensive rather than merely hypoxic. That is obstructive shock, and it is relieved by letting the air out, not by giving oxygen or fluid.
Site selection - the entry point is the safety triangle bounded by the lateral border of pectoralis major, the anterior border of latissimus dorsi and a line at the level of the nipple, usually the fourth or fifth interspace in the mid-axillary line, with ultrasound used to confirm fluid or absent lung sliding.
Local infiltration - lidocaine is laid into skin, down to the rib periosteum and through to the parietal pleura, and the same needle is used to aspirate air or fluid and confirm the space.
Blunt entry - a short incision one interspace below the target is deepened with forceps in a tunnel angled upward, and the pleura is entered just above the upper border of the rib to spare the intercostal neurovascular bundle running under the rib above.
Finger sweep and tube - a gloved finger confirms the pleural space and frees adhesions, then the tube is directed posteriorly and superiorly for air or basally for fluid, sutured in and dressed.
Seldinger variant - a small-bore pigtail catheter can be railroaded over a guidewire for a simple pneumothorax or free fluid, which hurts less but blocks more readily than a large blunt-dissected tube.
Connection and confirmation - the tube goes to an underwater seal with or without suction, and a chest radiograph confirms position and re-expansion.