The concept of chest tube drainage was first advocated by Hippocrates when he described the treatment of empyema by means of incision, cautery, and insertion of metal tubes.¹ The technique was not widely used until the influenza epidemic of 1917 which saw an increased use of intercostal drainage for postpneumonic empyema.² The use of chest tubes was imperative in the management of World War II causalities requiring thoracotomy and was reported in 1922 for postoperative care.³ The concept of emergency thoracostomy for acute trauma gained wider popularity following the Korean War in 1945.⁴ Today the use of chest tubes is part of the day-to-day management of acute trauma and care of thoracic surgery patients.

Chest tubes are indicated for both emergent and elective situations.^4–6 The most common indication for tube thoracostomy is pneumothorax and/or hemothorax. Other indications are summarized in Table 9-1. There are no absolute contraindications to drainage by means of chest tube, especially in the case of life-threatening emergency.⁴ Relative contraindications to chest tube insertion include postoperative inflammatory and infective pleural space adhesions, presence of a diaphragmatic hernia, or hepatic hydrothorax with documented coagulopathy.⁷

The essential steps to inserting a pleural drainage tube are summarized in Table 9-2. The technique can also be viewed online.⁸ Good insertion technique and appropriate post-insertion care are associated with less morbidity and shorter hospital stays.⁹ The most common site of insertion is the “safe triangle,” which as the name implies, is the safest entry into the chest.^10,11 The boundaries of this triangle are identified by the anterior border of the latissimus dorsi, the lateral border of the pectoralis major muscle, and a line superior to the horizontal level of the nipple and an apex below the axilla (Fig. 9-1). In this space, the likelihood of damaging vital structures during insertion is considerably low.¹² As the diaphragm can rise to the fifth rib at nipple level during expiration, chest tubes should be placed above this level to avoid inadvertent damage to abdominal structures.

An incision 1.5 to 2 cm in length is made parallel to the rib. A Kelly clamp or an artery forceps is used bluntly to dissect through the subcutaneous layers and intercostal muscles. The path of dissection should aim toward the upper superior intercostal space. A dissection plane is created through the subcutaneous tissue layers and the intercostal muscles on the superior surface of the rib. Adhering to the superior surface will avoid inadvertent injury to the neurovascular bundle located at the inferior surface. The blunt bevel of the dissecting instrument is used to gently puncture through the parietal pleura. Digital penetration (usually with the index finger) is followed to avoid puncturing any adjacent lung tissue. Once entry into the pleura is confirmed, the Kelly clamp is withdrawn and the tube is inserted along the established tract. When thoracostomy is needed to drain an apical pneumothorax, an anticlockwise wrist maneuver will permit the tube to slide away from the fissure and lie in the desired position in the apex of the lung. Mattress or interrupted sutures are used on both sides of the incision to close the ends (Fig. 9-2). The loose ends of the sutures are wrapped around the tube and tied to anchor the tube to the chest wall. The tube is then taped to the side of the patient and wrapped by a petroleum-based gauze dressing. Several pieces of regular sterile gauze and multiple pressure dressings are used to secure the chest tube in place. A chest x-ray is obtained to confirm placement.¹³