• Pneumothorax (2) in the following settings:
  1. hemodynamically unstable patient
  2. after needle decompression of a tension pneumothorax
  3. all patients with pneumothorax ventilated with positive pressure
  4. prior to air tranportation
  • Hemothorax (2)



  • Known adhesions of the lung to the chest wall
  • Caution in the setting of coagulopathy


  1. Prior

Prepare the Patient

  • Explain the procedure if the patient is awake
  • Optimal patient position (hand under head, head end height 30°)
  • Consider systemic analgesia / anxiolytics when needed in hemodynamically stable patients


Prepare the Equipment

  • Chest tube set and chest tube size (3)
  • Multi-chamber system with water seal or equivalent (eg Heimlich valve)
  • Equipment to fixate the chest tube (e.g. suture with 0/0, 1/0 el 2/0 equivalent)
  • Protective equipment (eg mouth protection, rock, sterile gloves)


  1. Procedure

Sterilize and Drape

  • Clean a large area of ​​hemithorax with alcohol or equivalent
  • Place sterile drapes around the work area


Analgesia and Anatomy

  • Identify the safe triangle (cranial to the nipple line)
  • Administer local anesthetic to the dermis, periostasis, intercostal muscles and pleura after aspiration
  • Sufficient dose, eg Lidocaine 1% (10 mg / ml) adults 20 ml, children: < 5 mg / kg


Incision and Dissection

  • 2-4 cm skin incision parallel to the ribs in anesthetized area (4)
  • Blunt dissection with forceps through subcutis to the rib
  • Blunt dissection over the cranial edge of the rib (5) until the pleura is reached (6)
  • The hole in the pleura is widened with the forceps or finger
  • Palpation, confirm that the lung is not adherent to the chest wall


Introducing the Chest Tube

  • Graps the distal part of the chest tube with the forceps (6)
  • The chest tube is inserted along side the finger that palpated the pleura (7)
  • Confirm that air or liquid passes through the chest tube
  • The chest tube is clamped (preferably close to the skin so that change of tube position can be detected)


Fixation and Connect

  • Fixate the chest tube so that it can withstand a traction of 2-3 kg (8)
  • Connect the chest tube to the water seal and start suction


  1. Post
  • Check for air / blood in the drain
  • Check for air leak around the incision
  • Re-evaluation the patient’s ABCs
  • Order a chest X-ray



1-Refers here only to indications for emergent chest tube insertion

2-Pneumo- or hemothorax based on clinical, sonographical or radiological suspicion

3-Tube size:

  • 12 – 20 F for children
  • 16 – 20 F for pneumothorax
  • 24 – 36 F for hemothorax

4-Method to garanty that the incision is carried out in the anesthetized area:

  • Mark the are somewhat prior to sterilization
  • Hold a finger on the area after local anesthesia while taking the scalpel
  • Leave the needle used to apply local anesthesia in the skin while taking the scalpel

5-The forceps is held 1 cm from the skin when pressure is applied to avoid penetrating too deeply

6-The trocar should not be used during the introdution of the chest tube

7-This technique is recommended to insure that the chest tube is not inadvertantly placed in the chest wall.

8-One of the techniques that is recommended ( select ”thoraxdrän”)