Chest tube

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Chest tube
Other names: Intercostal drain, chest drain, thoracic catheter, tube thoracostomy, intercostal catheter, Bülau drain
The free end of the chest tube is usually attached to an underwater seal, below the level of the chest. This allows the air or fluid to escape, but prevents anything returning to the chest.
SpecialtyEmergency medicine, general surgery
IndicationsPneumothorax, pleural effusion[1]
Steps1) Place person on back with hand behind their head[2]
2) Clean and inject local anesthetic into the area[2]
3) Make a 2 cm incision at the 5th intercostal space anterior axillary line[2]
4) Use Kelly forceps to dissect one intercostal space up and into the pleural cavity[2]
5) Replace the forceps with a finger to guide in the chest tube[2]
6) Suture, apply gauze, and tape the tube in place[2]
7) Attach the tube to the drainage system[2]
SuccessConfirmed by chest X-ray, bubbles in drainage system[2]
ComplicationsSubcutaneous emphysema, blockage of the tube, bleeding, infection, reexpansion pulmonary edema, lung or diaphragm injury[1]

A chest tube is a flexible plastic tube that is inserted through the chest wall into the pleural space.[1] It is used to remove air (pneumothorax), fluid (pleural effusion, hemothorax), or pus (empyema).[1] In those with a tension pneumothorax, a needle thoracostomy may be carried out first.[1]

The person is generally placed on their back, possibly with the head of the bed raised, and their hand behind their head.[2] After the area is cleaned with chlorhexidine and injected with local anesthetic, a 2 cm horizontal incision is make at the 4th or 5th intercostal space anterior axillary line.[2] Kelly forceps are than used to dissect one intercostal space up and into the pleura.[2] A finger may be placed in the hole to help guide in the chest tube.[2] The tube is aimed superiorly for air and inferiorly for fluid.[2] The tube is than sutured, gauze applied, and taped.[2] It is than connected to a drainage system.[2]

In a pneumothorax bubbles will be seen in the drainage system.[2] A chest X-ray is than carried out to confirm placement.[2] Antibiotics are often given to prevent infection.[3] The tube may be removed once air leakage has stopped for more than 12 to 24 hours or the amount of fluid out is under 200 ml per 24 hours.[2] Removal should occur when the person has taken and is holding a maximal breath.[2] Another chest X-rays is done after 12 to 24 hours.[2] Complications may include subcutaneous emphysema, blockage of the tube, bleeding, infection, reexpansion pulmonary edema, and lung or diaphragm injury.[1]

A chest tube was first used by Hippocrates around 400 BC to drain an empyema using a metal tube.[4][5] The addition of water seals came about in 1873.[6] Chest tubes became widely used in the 1920s, for post-pneumonic empyema as a result of the 1918 influenza pandemic.[6] Modern tubes sizes vary from 6 to 40 French (Fr) and are made from either silicone or polyvinyl chloride.[6] They generally have a number of holes at one end and a stripe along the side that appears bright on X-rays.[7]

Medical uses

Left-sided pneumothorax (right side of image) on CT scan of the chest with chest tube in place.

Tube size

In adults a tube size of 24 to 32 Fr may be used for an open technique.[8][9] Smaller tubes of 8 to 14 Fr may be used for catheter thoracostomy.[8]


When chest tubes are placed for either blunt or penetrating trauma, antibiotics decrease the risks of infectious complications.[10][3] Typically cephazolin is used as a single dose or for up to 2 days.[3] If more than 1500ml of blood initially comes out in the setting of trauma, or more than 200 cc/hr for 4 hours, a thoracotomy is indicated.[7]

Tube thoracostomy

A chest tube inserted on a persons right side

The free end of the tube is usually attached to an underwater seal, below the level of the chest. This allows the air or fluid to escape from the pleural space, and prevents anything returning to the chest. Alternatively, the tube can be attached to a flutter valve. This allows patients with pneumothorax to remain more mobile.

British Thoracic Society recommends the tube is inserted in an area described as the "safe zone", a region bordered by: the lateral border of pectoralis major, a horizontal line inferior to the axilla, the anterior border of latissimus dorsi and a horizontal line superior to the nipple.[11] More specifically, the tube is inserted into the 5th intercostal space slightly anterior to the mid axillary line.[12]

Chest tubes are usually inserted under local anesthesia. The skin in the area of insertion is first cleansed with antiseptic solution, before sterile drapes are placed around the area. The local anesthetic is injected into the skin and down to the muscle, and after the area is numb a small incision is made in the skin and a passage made through the skin and muscle into the chest. The tube is placed through this passage. If necessary, patients may be given additional analgesics for the procedure. Once the tube is in place it is sutured to the skin to prevent it falling out and a dressing applied to the area. Once the drain is in place, a chest radiograph will be taken to check the location of the drain. The tube stays in for as long as there is air or fluid to be removed, or risk of air gathering.

Chest tubes can also be placed using a trocar, which is a pointed metallic bar used to guide the tube through the chest wall. This method is less popular due to an increased risk of iatrogenic lung injury. Placement using the Seldinger technique, in which a blunt guidewire is passed through a needle (over which the chest tube is then inserted) has been described.

Protocols to maintain chest tube patency by preventing chest tube clogging are necessary.

Postoperative drainage

The placement technique for postoperative drainage (e.g. cardiac surgery) differs from the technique used for emergency situations. At the completion of open cardiac procedures, chest tubes are placed through separate stab incisions, typically near the inferior aspect of the sternotomy incision. In some instances multiple drains may be used to evacuate the mediastinal, pericardial, and pleural spaces. The drainage holes are placed inside the patient and the chest tube is passed out through the incision. Once the tube is in place, it is sutured to the skin to prevent movement. The chest tube is then connected to the drainage canister using additional tubing and connectors and connected to a suction source, typically regulated to -20 cm of water.[13]


Drain sponges which may be used as part of the dressing for a chest tube

After suturing, dressings are applied to cover the wound. First, a y-slit compress is used around the tube. Second, a compress (10 x 10 cm) is placed on top and finally an adhesive plaster is added in a way that tension is avoided. A bridle rein is recommended to fix the tube to the skin. This tape bridge will prevent the tube from moving backwards and the possibility to cause clogging. It also prevents pain as it reduces tension on the fixation stitch. Alternatively, a large adhesive plaster that functions like a tape bridge may be used.[14]

Tube management

Chest tubes should be kept free of dependent loops, kinks, and obstructions which may prevent drainage.[15] In general, chest tubes are not clamped except during insertion, removal, or when diagnosing air leaks.

Manual manipulation, often called milking, stripping, fan folding, or tapping, of chest tubes is commonly performed to clear chest tube obstructions. No conclusive evidence has demonstrated that any of these techniques are more effective than the others, and no method has shown to improve chest tube drainage.[16] Furthermore, chest tube manipulation has proved to increase negative pressure, which may be detrimental, and painful to the patient.[16] For these reasons, many hospitals do not allow these types of manual tube manipulations.[17]

One option is active chest tube clearance without breaking the sterile field. The 2019 ERAS Guidelines for Perioperative Care recommends active clearance of chest tubes to prevent retained blood and other complications.[18] This was given an IB-NR rating, meaning, it should routinely be performed. Makeshift efforts such as open chest tube clearing that involves breaking the sterile environment separating the chest tube from the drainage canister tubing to suction it out should not be performed (Class III, A).[19]


Relative contraindications to chest tube placement include a diaphragmatic hernia, as well as hepatic hydrothorax.[20] Additional relative contraindications include scarring in the pleural space (adhesions). It appears that a chest tube can still be safely placed in those with a coagulopathy.[21]

Insertion complications may include hemorrhage, infection, and reexpansion pulmonary edema. While it was previously believed that one should drain no more than 1.5 liters of fluid, the concerns appears unfounded, and draining all fluid present is generally reasonable.[1] Injury to the liver, spleen or diaphragm is possible if the tube is placed inferior to the pleural cavity. Injuries to the thoracic aorta and heart can also occur.[22]

The most common complication of a chest tube is chest tube clogging.[17] Another common complication after thoracic surgery that occurs in 30–50% is air leaks. If a chest tube clogs when there is an airleak the patient will develop a pneumothorax.[23] Here, digital chest drainage systems can provide real time information as they monitor intra-pleural pressure and air leak flow, constantly.[24]

Subcutaneous emphysema indicates backpressure created by undrained air, often caused by a clogged chest tube or insufficient negative pressure.[25] If a patient has subcutaneous emphysema, it is likely their chest tube is not draining and consideration should be given if it should be unclogged or another tube should be placed so that the air leaking from the lung can be adequately drained.



Size of chest tube:
Adult male = 28–32 Fr
Pp Adult female = 28 Fr
Child = 18 Fr
Newborn = 12–14 Fr
Chest tube drainage holes

Chest tubes are commonly made from clear plastics like PVC and soft silicone. Chest tubes are made in a range of sizes measured by their external diameter from 6 Fr to 40 Fr. Chest tubes, like most catheters, are measured in French catheter scale. For adults, 20 Fr to 40 Fr (6.7 to 13.3mm external diameter) are commonly used, and 6 Fr to 26 Fr for children. Conventional chest tubes feature multiple drainage fenestrations in the section of the tube which resides inside the patient, as well as distance markers along the length of the tube, and a radiopaque stripe which outlines the first drainage hole.[22] Chest tubes are also provided in right angle, trocar, flared, and tapered configurations for different drainage needs. As well, some chest tubes are coated with heparin to help prevent thrombus formation, though the effect of this is disputed.[27]

Chest tube have an end hole (proximal, toward the patient) and a series of side holes. The number of side holes is generally 6 on most chest tubes. The length of tube that has side holes is the effective drainage length (EDL). In chest tubes designed for pediatric heart surgery, the EDL is shorter, generally by only having 4 side holes.[28]

Channel style chest drains, also called Blake drains, are so-called silastic drains made of silicone and feature open flutes that reside inside the patient. Drainage is thought to be achieved by capillary action, allowing the fluids to travel through the open grooves into a closed cross section, which contains the fluid and allows it to be suctioned through the tube.[13] Though these chest tubes are more expensive than conventional ones, they are theoretically less painful.[29]

Chest drainage system

Chest tube drainage system diagram, with parts labeled in
Portable electronic system

A chest drainage system is typically used to collect chest drainage (air, blood, effusions). Most commonly, drainage systems use three chambers which are based on the three-bottle system. The first chamber allows fluid that is drained from the chest to be collected. The second chamber functions as a "water seal", which acts as a one way valve allowing gas to escape, but not reenter the chest. Air bubbling through the water seal chamber is usual when the patient coughs or exhales but may indicate, if continual, a pleural or system leak that should be evaluated critically. It can also indicate a leak of air from the lung. The third chamber is the suction control chamber. The height of the water in this chamber regulates the negative pressure applied to the system. A gentle bubbling through the water column minimizes evaporation of the fluid and indicates that the suction is being regulated to the height of the water column. In this way, increased wall suction does not increase the negative pressure of the system. Newer drainage systems eliminate the water seal using a mechanical check-valve, and some also use a mechanical regulator to regulate the suction pressure. Systems which employ both these are dubbed "dry" systems, whereas systems that retain the water seal but use a mechanical regulator are called "wet-dry" systems. Systems which use a water seal and water column regulator are called "wet" systems. Dry systems are advantageous as tip-overs of wet systems can spill and mix with blood, mandating the replacement of the system. Even newer systems are smaller and more ambulatory so the patient can be sent home for drainage if indicated.[22]

More recently digital or electronic chest drainage systems have been introduced. An onboard motor is used as vacuum source along with an integrated suction control canister and water seal. These systems monitor the patient and will alert if the measured data are out of range. Due to the digital control of the negative pressure, the system is able to objectively quantify the presence of a pleural or system leak. Digital drainage systems allow clinicians to mobilize patients early, even for those on continuous suction, which is difficult to accomplish with the traditional water-seal system under suction.[23][30] Recently published clinical data indicates, that application of such systems can also lead to a reduction in complications.[31][32]


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