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Chest Tube Care: Tube Thoracostomy Management Strategies

What is tube thoracostomy?

Tube thoracostomy is a chest drain used to remove fluid from around the lungs, easing pressure on breathing.Tube thoracostomy is a chest drain used to remove fluid from around the lungs, easing pressure on breathing.

Tube thoracostomy, also known as open chest drainage, is a surgical procedure to drain the collection of pleural fluid, air, blood, or pus from the pleural cavity through a tube inserted in your chest.

The pleural cavity is the space lying between the pleura (visceral and parietal), the two thin layers that surround the lungs. This space contains a small amount of liquid known as pleural fluid, which acts as a lubricant for the expansion and contraction of the lungs during respiration. When there is an excessive collection of pleural fluid or build-up of air, blood, or pus in the pleural cavity, you will start having trouble breathing. In such conditions, tube thoracostomy eases breathing.

Why is a tube thoracostomy performed?

In some situations, such as severe traumatic injuries to the chest, tube thoracostomy becomes an emergency and a life-saving procedure. It is also performed as a pre-planned procedure in certain diseases that cause buildup of fluid or air in the pleural cavity.

Tube thoracostomy is performed if the patient develops:

  • Pleural effusion: Excessive collection of pleural fluid in the pleural cavity
  • Pneumothorax: Leakage of air in the pleural activity
  • Hemothorax: Collection of blood in the pleural cavity
  • Hemopneumothorax: Collection of blood as well as air in the pleural cavity
  • Hydrothorax: Collection of fluid in the pleural cavity due to organ (liver or heart)  failure
  • Chylothorax: Collection of lymphatic fluid (chyle) in the pleural cavity
  • Empyema:  Collection of pus in the pleural cavity.

What are the guidelines for tube thoracostomy management?

Surgeons follow a certain set of rules (guidelines) for any surgical procedure. The guidelines for tube thoracostomy include:

Procedure preparation

  • The patient is screened for clotting or bleeding disorder with certain blood tests.
  • If one of the patient’s lungs has been removed (pneumonectomy), the surgeon will consult a cardiothoracic surgeon to drain the post-pneumonectomy space. 
  • If the chest drain insertion is a pre-planned procedure, the blood-thinning medication, warfarin will be discontinued for a few days before the procedure.
  • Prior to commencing chest tube insertion, the surgeon will explain the procedure to the patient and obtain aformal, written consent from the patient or their family.
  • The patient will be given a sedative medicine (benzodiazepine or opioid) to make them relaxed throughout the procedure.
  • The patient will lie on their back or sit and lean forwards.
  • The skin below the armpit will be marked with a pen.


  • The surgeon will check if they can draw free air or fluid from the marked area. 
  • A chest X-ray or an ultrasonography (USG) will be used to select the appropriate site for chest tube placement.
  • The marked area will be cleaned with a sterile solution before inserting the chest tube.
  • Antibiotics will be started if the patient has accidental injuries.
  • An anesthetic will be injected into the marked site prior to insertion of the chest tube,
  • Chest tube insertion will be performed without substantial force.
  • The chest tube may have valves at its insertion, and it is connected directly to the outside collection chamber, which collects drainage from the chest cavity. 

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What are the strategies for tube thoracostomy management?

In patients with empyema or pleural effusion, initial removal of 50-200 mL of fluid using a syringe attached to a needle may be done prior to the insertion of the chest tube.

The incision will be made over the rib to minimize the risks of injury to the nerve and blood vessels that follow the lower margin of each rib.

Small-bore drains are recommended, as they are more comfortable than larger-bore tubes. Large-bore drains are recommended for drainage of acute hemothorax and to check for further blood loss. 

  • The strategies for managing the complications of tube thoracostomy are as follows:
  • If the chest tube has been placed too far into the chest, it will be retracted
  • If the chest tube goes into the abdominal space, it will be removed.
  • If bleeding occurs at the incision site, it will be stopped by pressing on it tightly.
  • If bleeding occurs in the chest and does not resolve spontaneously, the chest might be opened (thoracotomy).
  • Bleeding in the abdomen which is as result of liver or spleen injury requires emergency opening of the abdomen (laparotomy)
  • Persistent pneumothorax or hemothorax might require insertion of a new chest tube.
  • If the patient starts coughing or experiences chest tightness, the surgeon will end the procedure. 
  • Most experts recommend removal of no more than 1-1.5 L of fluid at any one time. 

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