Chest drain insertion and care

What it is

A chest drain (intercostal drain, chest tube) keeps the pleural space empty of air or fluid until the cause settles. Small-bore drains placed by the Seldinger technique (needle, guidewire, dilator, drain) suit most pneumothoraces and free-flowing effusions, and are more comfortable. Large-bore drains placed by blunt dissection are preferred for haemothorax and trauma, where blood and clots must pass. The usual site is the triangle of safety: bounded by the lateral edge of pectoralis major in front, the lateral edge of latissimus dorsi behind, and a horizontal line at the level of the nipple (about the 5th intercostal space) below, with the apex below the axilla. Inserting there avoids the internal thoracic vessels, the long thoracic nerve and, mostly, the diaphragm and abdominal organs. The drain connects to an underwater seal, a one-way valve that lets air and fluid out but not back in; the bottle must stay below the level of the chest. Daily care checks three things: whether the fluid column swings with breathing (the tube is in the pleural space and patent), whether it bubbles (an ongoing air leak) and how much it drains.

Indications

• Pneumothorax after needle decompression, in ventilated patients, secondary or large symptomatic, or after failed aspiration.
• Haemothorax and traumatic haemopneumothorax (large-bore drain).
• Empyema or complicated parapneumonic effusion (pus, low pH or organisms in the fluid).
• Malignant or recurrent effusion, before pleurodesis.
• After thoracic or cardiac surgery, and for chylothorax.

Contraindications and precautions

• Lung adherent to the chest wall at the site (previous pleurodesis or surgery): use imaging to choose another site.
• Uncertainty between a large bulla and a pneumothorax, or collapse and effusion: get a CT or ultrasound first.
• Coagulopathy or anticoagulants: correct or weigh the urgency where possible.
• Skin infection at the site; post-pneumonectomy space needs a specialist.
• Emergencies (tension, massive haemothorax) override relative contraindications.

Equipment

• Drain of the chosen size: Seldinger set (needle, guidewire, dilator, drain) or large-bore tube with blunt dissection set.
• Underwater seal bottle filled to the marked level with sterile water, and connecting tubing.
• Sterile gloves, gown, drape, antiseptic, scalpel, forceps and a strong non-absorbable suture to secure the drain.
• Local anaesthetic, needles and syringes; analgesia or sedation as needed.
• Monitoring, oxygen, ultrasound, and a dressing that holds the drain without kinking it.

Step by step (and why)

1. Confirm the side and indication on imaging and at the bedside; consent — a drain in the wrong side is a never event.
2. Position semi-reclined with the arm behind the head — this opens the triangle of safety and moves the scapula away.
3. Mark the site in the triangle of safety, using ultrasound for fluid — this avoids the vessels, nerves and abdomen.
4. Clean, drape and infiltrate local anaesthetic to the pleura — aspirating air or fluid confirms the depth.
5. Seldinger: needle over the upper rib border, guidewire, dilator, drain — the wire guides each step into the space.
6. Blunt: incise along the rib, dissect over its upper border, sweep a finger inside — this checks for lung adhesions.
7. Connect to the underwater seal and check for swinging and bubbling — this shows the tube is in the pleural space.
8. Suture the drain securely and dress without kinking — a drain that falls out is the most common avoidable problem.
9. Get a chest X-ray and record size, site, depth mark and output — this confirms position and gives a baseline.

Complications

• Malposition: subcutaneous, in a fissure, in the abdomen or against the mediastinum.
• Organ injury (lung, liver, spleen, heart, great vessels), mostly with trocars or a site that is too low.
• Bleeding from intercostal vessels, and surgical (subcutaneous) emphysema.
• Infection at the site or empyema; re-expansion pulmonary oedema after rapid drainage.
• Blockage, kinking, disconnection or dislodgement, and pain that limits breathing and coughing.

Next step

• Review the drain every day: swing, bubbling, volume and type of output, site and the patient's pain.
• A sudden stop in swinging, new breathlessness or surgical emphysema: check the tube, get an X-ray and call a senior.
• Persistent air leak after several days: discuss suction and referral to thoracic surgery.
• Remove when the lung is re-expanded and bubbling has stopped, or the output is low; then repeat the X-ray.
• Send any fluid for the same tests as a pleural aspiration and plan treatment of the cause.

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Elsewhere in DurgiPedia

• Chest tube: assisting insertion, the drainage system and care
• Lines and tubes on the chest X-ray: where each tip should be
• Pneumothorax on the chest X-ray

Connections

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Educational content; it does not replace supervised hands-on training, your institution's protocols or a prescriber's order. A procedure is learnt with a teacher and done only once you are trained to do it.

Sources: Care of a Chest Tube (StatPearls (NCBI Bookshelf), 2025); Acute Pneumothorax Evaluation and Treatment (StatPearls (NCBI Bookshelf), 2025).

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Representative model, for educational purposes only.