Chest tube placement, or tube thoracostomy, can be an anxiety-provoking procedure for both the patient AND the operator. It can also be a very gratifying procedure for the operator when performed successfully and without patient discomfort.
Here are a few tips that will improve the success rate of chest tube placement without any complications. The first hint is to place the patient in a semi-upright position (45 degrees) so that the diaphragm is lowered by gravity. Also, it is important to secure the ipsilateral arm above the head using a wrist restraint tied to the bedframe on the contralateral side. Try to avoid making your incision below the fourth intercostal space in the mid-axillary line to make sure that you are inserting the chest tube above the diaphragm. Another important point to remember is to make a wide enough incision. Too frequently, I will see my residents make a tiny incision and struggle to place the chest tube. Especially in this era of morbid obesity, make an incision that is at least 3 cm in length and wider if patients are more obese. Remember to place the chest tube just over the top of the rib to avoid injuring the intercostal artery. Finally, it takes a lot of force to introduce the curved Kelly clamp into the pleural space. This is the step that can lead to parenchymal lung injuries if the clamp is slammed too deep when the pleural space is entered. To minimize this complication, use your non-dominant hand to hold the middle of the clamp such that the back of this hand will hit the chest wall during pleural entry and prevent lung injury.
In addition, chest tube placement, or tube thoracostomy, is one of the most brutal bedside procedures performed in the ER or in the ICU. Frequently, you can hear the patient screaming while the chest tube is being inserted. Please don’t torture your patients like this. Give them procedural sedation and ample local anesthesia so that they can be comfortable during this procedure. Remember that you can use up to 4.5 mg/kg subcutaneous lidocaine or 7 mg/kg lidocaine with epinephrine (30 mL 1% lidocaine or 49 mL 1% lidocaine with epi for a 70 kg patient) for local anesthesia. I also routinely give procedural sedation for all non-emergent chest tubes. My favorite regimen is to use ketofol (0.75 mg/kg ketamine IV and 0.75 mg/kg propofol) or ketamine 1.5 mg/kg IV alone. I have rarely had issues with hypoventilation, airway patency, or hemodynamic compromise and my patients are never uncomfortable.
Please keep your patients comfortable during tube thoracostomy. You won’t believe how this minimizes the stress level of everybody involved: the patient, the staff AND YOU!
