Incision and Dissection

  1. With the scalpel, create a 1.5 to 2cm incision through the skin at the marked incision site
  2. With a curved blunt dissecting instrument (e.g. Kelly clamp), dissect the subcutaneous tissues until the intercostal muscle layer is reached
  3. Staying on top of the rib to avoid the neurovascular bundle running along the inferior rib margin, guide the blunt dissecting instrument upwards, towards the insertion site. This will create a diagonal path for the chest tube which is thought to provide a better seal against air leaks
  4. If using a larger caliber chest tube (24-Fr or greater), use your index finger to explore the tract created by the instrument, this will ensure that the tract will be large enough to accommodate the larger tube
  5. Once you have reached the parietal pleura, push the clamp gently through the parietal pleura, you should feel a "give", or a release of resistance. Ensure that adequate local anesthesia is attained prior to proceeding with this step. Alternatively, you may use your finger to advance into the parietal space. Often, pleural fluid may trickle out through the tract
  6. Once you have gained access to the pleural space, use your index finger to make sure the lung is not adherent to the pleural wall as this would impede the passage of the tube. If possible, leave your finger in the tract as a guide for the tube
  7. Clamp the free end of the tube
  8. Using your finger as a guide, pass the tube into the pleural space. This allows you to feel the tube entering the pleural space and avoid subcutaneous dissection with the tube. Some clinicians prefer to pass the tube alone, others recommend that the tube be held in a large curved clamp, with the tube tip protruding from the jaws. Whichever way you choose, it is important to remember that you should NEVER force a tube into the pleural space!
  9. If the tube is meant to evacuate a pneumothorax, aim it apically. If the tube is meant to evacuate fluid, aim it basally
  10. Make note of the depth of tube insertion via the numbers marked on the tube