How to Place a Chest Tube: Step-by-Step Procedure

Chest tube placement, formally called tube thoracostomy, is a bedside procedure that involves inserting a flexible plastic tube through the chest wall and into the pleural space to drain trapped air, blood, or fluid. It is one of the most commonly performed emergency and surgical procedures, yet the technique demands careful attention to anatomy, patient preparation, and post-insertion management to avoid serious complications. The procedure follows a reliable sequence of steps, but understanding why each step matters is just as important as knowing the order.

Why Chest Tubes Are Placed

The pleural space is the thin gap between the lung and the chest wall. Under normal conditions it holds only a small amount of lubricating fluid and maintains a slight negative pressure that keeps the lungs expanded. When air, blood, pus, or other fluid accumulates in that space, the lung on the affected side can partially or fully collapse. A chest tube provides a route to evacuate that material, restore normal pressure, and let the lung re-expand.¹

The most common reasons for placing a chest tube include:

• Pneumothorax: air leaking into the pleural space, often from trauma or spontaneous lung blebs.
• Hemothorax: blood collecting in the pleural space, usually after chest trauma or surgery.
• Pleural effusion: excess fluid from infection, cancer, heart failure, or other medical conditions.
• Empyema: infected pus in the pleural space that needs to be drained and potentially treated with irrigation.

In emergency settings such as trauma bays, placement is sometimes done within minutes of a patient arriving. In less urgent situations, it can be planned, with imaging and lab work guiding the decision beforehand.

Choosing the Right Tube

Chest tubes come in a range of sizes, measured in French (Fr) units, from small-bore catheters (around 8 to 14 Fr) to large-bore tubes (28 to 36 Fr or larger). The conventional wisdom has been to match the tube size to the problem: larger tubes for blood or thick pus, smaller tubes for air or thin fluid. In practice, research suggests that physicians do not always follow a strict formula. A study of emergency physicians managing traumatic pneumothorax and hemothorax found that the initial tube size chosen was not related to the patient’s sex, body size, injury severity, or respiratory status.² That finding hints at how much clinical judgment and institutional habit play into the choice.

Small-bore catheters placed using a guidewire technique have gained popularity for simple pneumothorax and uncomplicated effusions, since they cause less discomfort and require a smaller incision. Large-bore tubes remain the standard when rapid drainage of blood or thick material is expected, because they are far less likely to clog.

Identifying the Insertion Site

Getting the location right is arguably the most critical safety step. The classic teaching is to aim for the “safe triangle,” a zone on the lateral chest wall bounded by the front edge of the latissimus dorsi muscle, the lateral border of the pectoralis major, and a horizontal line at the level of the nipple or roughly the fourth to fifth intercostal space. The goal is to enter above the rib’s upper border to avoid the nerve, artery, and vein that run along each rib’s lower margin.

Landmark accuracy varies more than many clinicians expect. A retrospective study of trauma patients evaluated four common landmark methods for selecting the tube insertion point. On the right side, using the mid-sternum level as a reference point avoided the diaphragm in about 93% of patients, compared with only 82% when using the traditional fifth intercostal space.³ On the left side, both methods performed well, with diaphragm avoidance rates above 97%. The practical takeaway is that the right hemidiaphragm sits higher, making right-sided insertions more prone to inadvertent diaphragm puncture if the landmark is off.

Why Ultrasound Makes a Difference

Point-of-care ultrasound has changed the game for chest tube placement. Historically, clinicians relied entirely on anatomical landmarks and feel, but the diaphragm’s position shifts with breathing, body habitus, and patient positioning. A study examining this found that about one in five diaphragms was either consistently above or crossing the fifth intercostal space during the respiratory cycle. On the right side, the rate was 20%; on the left, 18%. Overall, ultrasound identified a hazardous insertion point roughly a quarter of the time that blind landmarks alone would have missed.⁴

This is not a trivial concern. Inserting a tube too low risks penetrating the diaphragm and injuring abdominal organs like the liver or spleen. When time permits, scanning the chest beforehand confirms where the diaphragm sits and where the fluid or air is located. For small-bore drains placed via the Seldinger technique, ultrasound guidance throughout the procedure is increasingly considered standard. A retrospective analysis of ultrasound-guided small-bore drain placement on a general medicine ward described how ultrasound was used to identify the optimal site, guide needle entry into the pleural space, confirm guidewire placement, and verify the drain’s final position.⁵

Numbing the Area

Chest tube insertion is painful, and adequate anesthesia matters both for patient comfort and for the proceduralist’s ability to work carefully. The standard approach uses local anesthetic, typically lidocaine or bupivacaine, injected layer by layer from the skin through the subcutaneous tissue, the intercostal muscles, and down to the parietal pleura, which is the most pain-sensitive layer.

A randomized controlled trial comparing intercostal nerve block to standard local anesthesia for tube insertion used 15 mL of 0.5% bupivacaine in each group.⁶ In critically ill or intubated patients, systemic sedation and analgesia supplement local anesthesia. In awake patients, some centers give an anxiolytic or a small dose of intravenous opioid beforehand, especially if the patient is already in distress.

The Step-by-Step Insertion

Once the site is marked, the skin prepped with antiseptic, and the local anesthetic given time to take effect, the procedure follows a predictable sequence. A useful teaching mnemonic captures the essentials: FINGER, which stands for Find landmarks, Inject lidocaine, No infection allowed (sterile prep), Generous incision, Enter pleural space, and Reach in with finger to sweep and reassess.⁷

Skin Incision and Dissection

A horizontal incision, usually 3 to 5 centimeters long, is made over the rib one intercostal space below the intended entry point. This offset creates a subcutaneous tunnel that helps seal the tract once the tube is eventually removed. Using a curved clamp (often a Kelly or large curved hemostat), the clinician dissects bluntly through the subcutaneous tissue and intercostal muscles, staying just above the upper border of the rib to avoid the neurovascular bundle running along the rib’s lower edge. When the clamp pops through the parietal pleura, there is often a rush of air or fluid, confirming entry into the pleural space.

Finger Exploration

Before inserting the tube, the clinician inserts a gloved finger through the tract and into the pleural space. This step serves several purposes: it confirms that the space has actually been entered, it breaks up any superficial adhesions that might block the tube’s path, and it verifies that no abdominal organs are within reach. Skipping the finger sweep is one of the more common shortcuts that lead to complications, because it removes the last tactile safeguard against malpositioned tubes.

Tube Insertion and Positioning

The chest tube, with its tip guided by the clamp or by hand, is advanced through the tract and into the pleural space. For pneumothorax, the tube is typically directed toward the apex (top) of the chest cavity, since air rises. For fluid collections, the tube is angled posteriorly and toward the base, where fluid pools when the patient is upright or semi-reclined. All the drainage holes in the tube must be inside the pleural space; if even one hole sits in the chest wall, air can leak into the subcutaneous tissue and the system will not drain properly.

Securing the Tube

A chest tube that slips out or kinks is worse than useless, so fixation gets serious attention. There is no universal consensus on the best method, though most clinicians use sutures, adhesive dressings, or a combination of both. A scoping review cataloged nine distinct principles used to fix chest drains, ranging from sutures passed through the tube to balloon-tipped catheters that anchor from inside, to subcutaneous tunneling of the tube itself. The review found that combining sutures with dressings, cable ties, or balloon catheters appeared to enhance security, and that in lab testing the highest pull-out force was achieved with a modified technique known as the Jo’berg knot.⁸

In practice, most centers use a heavy silk suture both to close the skin around the tube and to tie it to the tube itself. A purse-string or mattress stitch is placed around the insertion site so that when the tube is eventually pulled, the suture can be tightened to close the wound. An occlusive dressing is applied over the site to keep it airtight and clean.

Connecting to the Drainage System

The tube is connected to an underwater seal or a commercially made drainage unit. The basic principle is simple: the distal end of the tube sits below a water level inside the collection chamber. Air or fluid draining from the chest bubbles through the water and out, but outside air cannot travel back up and into the pleural space. That one-way mechanism is what makes the system work.⁹

Many setups add suction, typically set at negative 10 to 20 cm of water pressure, to speed evacuation and help the lung re-expand. Whether suction is necessary or whether passive (gravity) drainage suffices depends on the underlying condition. A large pneumothorax with an ongoing air leak usually benefits from suction; a slowly accumulating effusion may do fine with gravity alone.

Confirming Correct Placement

After insertion, a chest X-ray is the standard way to verify that the tube is in the right position and the lung is re-expanding. The X-ray also serves as a baseline: if the patient worsens later, clinicians compare subsequent images to this first one. In some facilities, ultrasound is used as an adjunct or even a replacement for the initial X-ray, particularly when repeated imaging would be logistically difficult.

Clinicians also watch the drainage system itself. Bubbling in the water seal chamber suggests an ongoing air leak. Fluid swinging back and forth in the tube with each breath (called “tidaling”) confirms that the tube is patent and in the pleural space. If the tube stops swinging or draining abruptly, it may be kinked, clotted, or displaced.

One complication to watch for in the immediate post-insertion period is re-expansion pulmonary edema, which can occur when a lung that has been collapsed for an extended period suddenly re-inflates. Symptoms include cough, worsening shortness of breath, and frothy sputum, and early recognition is important.¹⁰

What Can Go Wrong

Chest tube complications divide into two broad categories: technical problems and infections. A review of tube thoracostomy complications listed malposition, blocked drains, dislodgement, re-expansion pulmonary edema, subcutaneous emphysema, nerve injuries, vascular and cardiac injuries, esophageal injuries, residual pneumothorax after removal, and even tumor recurrence at the insertion site as potential technical issues. Infective complications include empyema and surgical site infection. The same review noted that complication rates are higher when tubes are placed using the older trocar technique, where the tube is forced through the chest wall on a sharp stylet, compared with the blunt dissection approach described above.¹¹

Setting matters, too. A study examining complications across a regional trauma system found that patients whose chest tubes were placed outside a designated trauma center had roughly seven times the odds of tube malposition, about six times the odds of a residual hemothorax, and nearly seven times the odds of a residual pneumothorax compared to those treated at the trauma center. These patients were also nearly four times as likely to need a second chest tube.¹² The findings underscore how much operator experience and institutional resources influence outcomes for what might seem like a straightforward procedure.

The Seldinger Alternative

Not every chest tube is placed through a surgical incision. The Seldinger technique uses a needle, guidewire, and dilator to place a smaller-bore catheter without blunt dissection. A needle is advanced into the pleural space (often under ultrasound guidance), a guidewire is threaded through the needle, the needle is withdrawn, the tract is dilated over the wire, and the catheter slides into place. The technique is less invasive and less painful, and it works well for straightforward pneumothorax and free-flowing pleural effusions.

There are limits, though. In pediatric empyema, for example, a comparison of percutaneous pigtail catheters placed via Seldinger technique versus standard surgical tube thoracostomy found that treatment failure was significantly higher in the pigtail catheter group, at 43% compared with 14%.¹³ Thicker material like pus or blood clots can obstruct the narrow lumen of a small catheter, and the lack of a finger sweep means there is no tactile confirmation that the tube has entered the right space. For trauma patients with potential hemothorax, the blunt dissection technique with a large-bore tube remains the default.

When and How the Tube Comes Out

Removal timing depends on the reason the tube was placed and what the drainage system shows. A prospective clinical study of chest tube removal in thoracic trauma patients outlined a protocol with three criteria that all had to be met before pulling the tube: no visible air leak while suction is applied, less than 200 mL of fluid output over the previous 24 hours, and a chest X-ray showing a fully expanded lung with clear costophrenic angles.¹⁴ The 200 mL threshold is based on the body’s normal rate of pleural fluid production, roughly 0.15 mL per kilogram per hour. Once output drops below that, the system is considered resolved enough to remove.

The removal itself requires coordination. The patient takes a deep breath in and holds it (or sometimes exhales fully, depending on institutional preference) to minimize the chance of air rushing back in as the tube exits. The suture holding the tube is cut, the tube is pulled swiftly, and the pre-placed purse-string stitch is tied down to seal the wound. A follow-up chest X-ray is typically obtained within a few hours to confirm no recurrent pneumothorax.

How Chest Drainage Evolved

Draining the chest is not a modern invention. The concept goes back to Hippocrates, who described draining pus from the pleural space using open incisions and metal tubes. For most of the intervening centuries, the technique was crude and carried enormous infection risk. The real breakthrough came in the 19th century with the development of closed drainage systems, which prevented outside air from entering the chest during drainage. Later innovations included the Heimlich valve, a one-way flutter valve small enough to allow patients to be ambulatory, and the shift from rubber to modern plastic tubing.¹⁵

Today’s commercially available drainage units are compact, integrate the water seal and suction chambers into a single disposable device, and have become increasingly portable. Digital drainage systems that measure air leak and fluid output continuously are entering clinical use, and some allow patients with resolving pneumothorax to be managed on an outpatient basis rather than staying in a hospital bed tethered to wall suction. The procedure itself has changed less than the equipment around it, but the addition of ultrasound guidance and smaller-bore catheter options has made the overall process safer and more adaptable than at any point in its long history.