Chest Tube / Tube Thoracostomy
What the Examiner Expects
Insertion of a drainage tube into the pleural space through the chest wall. The examiner expects you to describe the safe technique: incision at the 5th intercostal space anterior to the mid-axillary line, blunt dissection through subcutaneous tissue and intercostal muscles OVER the top of the rib (to avoid the intercostal neurovascular bundle running along the inferior rib border), finger sweep to confirm entry into the pleural space and absence of adhesions, then directed tube insertion. For trauma hemothorax, > 1500 mL of immediate output or > 200 mL/hr for 2–4 consecutive hours is an indication for operative thoracotomy.
Key Examiner Focus Points
- Insertion site: 5th intercostal space, anterior to mid-axillary line (safe triangle)
- Indications: pneumothorax, hemothorax, empyema, pleural effusion
- Massive hemothorax (> 1500 mL initial output or > 200 mL/hr for 2–4 hrs): OR thoracotomy
- Use blunt dissection and finger sweep before inserting — avoid lung injury
- 28–36 Fr tube for hemothorax; 20–28 Fr for pneumothorax
Common Curveballs
Initial output is 1200 mL of blood — does this require surgery?
Not yet based on initial output alone (threshold is 1500 mL). However, closely monitor hourly output. If drainage exceeds 200 mL/hr for 2–4 hours, take the patient to the OR. Also monitor hemodynamic status — if the patient becomes unstable despite resuscitation, operate regardless of drain output.
Chest tube is placed but the lung fails to re-expand with a persistent air leak
Ensure the tube is properly positioned (chest X-ray), all tube holes are within the pleural space, and the system is functioning. A persistent air leak suggests a major bronchial injury — obtain bronchoscopy. If the lung remains trapped with ongoing air leak, the patient may need VATS or thoracotomy for repair.
Practice this topic with an AI-powered mock oral exam.
Browse Practice Cases