Chest Tube Placement: Indications, Tube Size, Insertion Site and Technique

Quick Answer

A chest tube (tube thoracostomy) is a drain placed through the chest wall into the pleural space to remove air, blood, pus or other fluid. It is indicated for pneumothorax that is large, traumatic, tension, recurrent or present in a ventilated patient, and for hemothorax, empyema and large symptomatic effusions. Insert it in the triangle of safety, usually at the 4th or 5th intercostal space in the anterior to midaxillary line, over the upper edge of the rib. Malposition is the most common complication, and a supine AP chest x-ray can miss it.

When Is a Chest Tube Indicated?

A chest tube is indicated when air or fluid in the pleural space needs continuous drainage. The Merck Manual procedure guide (reviewed May 2025) lists these indications:

• Pneumothorax that is recurrent, persistent, traumatic, large, tension or bilateral
• Any pneumothorax in a patient on positive-pressure ventilation
• Symptomatic or recurrent large pleural effusion
• Empyema or complicated parapneumonic effusion
• Hemothorax
• Chylothorax

The ventilated patient gets a lower threshold: Merck treats any pneumothorax on positive-pressure ventilation as an indication. And if you decompressed a tension pneumothorax with a needle, the StatPearls review of tension pneumothorax (updated 2025) calls for a chest tube to follow.

Contraindications

There are few true contraindications. A review of tube thoracostomy technique in the Journal of Thoracic Disease (2014) notes that published guidelines list no absolute contraindications except a lung completely adherent to the chest wall throughout the hemithorax, or patient refusal.

Relative contraindications in the same review include coagulopathy or anticoagulation, infection over the insertion site, multiple pleural adhesions, emphysematous blebs and scarring. Where time allows, correct the coagulopathy and pick a different site away from infected skin.

Chest Tube Sizes: What Size Tube for Which Indication?

Size by indication, then check whether the evidence lets you go smaller. Merck’s sizing reflects traditional practice:

Indication	Merck Manual size (2025)	What trial and guideline evidence adds
Pneumothorax	20–24 Fr	A 14 Fr pigtail resolved uncomplicated traumatic pneumothorax as well as a 28 Fr tube, with less pain (Kulvatunyou 2014)
Malignant pleural effusion	20–24 Fr	Not studied in the sources here
Complicated parapneumonic effusion, empyema, bronchopleural fistula	28–36 Fr	Not studied in the sources here
Hemothorax	32–36 Fr	28–32 Fr matched 36–40 Fr (Inaba 2012); 14 Fr pigtail matched 28–32 Fr in stable patients (Kulvatunyou 2021); EAST conditionally recommends pigtails in stable patients (2021)

The case for smaller tubes in trauma is now reasonably strong. A prospective study of chest tube size in 293 trauma patients (Inaba, 2012) compared 28–32 Fr with 36–40 Fr tubes and found no difference in retained hemothorax (11.8% vs 10.7%), empyema, or the need for reinsertion or further procedures. Pain scores were similar too.

Pigtail catheters push the same question further. In a randomized trial in traumatic pneumothorax (Kulvatunyou, 2014), 40 patients received a 14 Fr pigtail or a 28 Fr chest tube. Resolution rates were similar, and insertion-site pain was lower with the pigtail (mean 3.2 vs 7.7 on a numeric scale after insertion).

For hemothorax, a multicenter randomized trial (Kulvatunyou, 2021) compared 14 Fr percutaneous catheters with 28–32 Fr chest tubes in 119 patients. Failure, defined as retained hemothorax needing a second intervention, was 11% vs 13% (p=0.74). The trial excluded patients in extremis who needed an emergent tube, and it stopped short of its planned enrollment.

Guidelines have followed, with limits. The EAST hemothorax guideline (Patel, 2021) conditionally recommends pigtail catheters for traumatic hemothorax in hemodynamically stable patients, based mostly on low-quality retrospective evidence. Merck adds a practical warning: catheters of 14 Fr or smaller can clog with clot in bloody effusions. Neither the trial nor the guideline supports a pigtail in the unstable, bleeding patient.

Chest Tube Insertion Site: The Triangle of Safety

Place the tube in the triangle of safety. The British Thoracic Society defines it by the anterior border of latissimus dorsi, the lateral border of pectoralis major, a line superior to the horizontal level of the nipple, and an apex below the axilla, as described in the 2014 tube thoracostomy review.

Within that triangle, Merck uses the 4th intercostal space for pneumothorax and the 5th for other indications, at the midaxillary or anterior axillary line. The neurovascular bundle runs along the lower edge of each rib, so the tube goes over the upper edge of the rib below your chosen space.

Going too low is the classic error. In a survey of junior doctors (Griffiths, 2005), 45% of 55 respondents marked a pneumothorax drain site outside the safe triangle, and the most common mistake was a site too low (24%). A low tube risks the diaphragm and the abdomen, and the 2014 review lists spleen, liver and stomach injuries from tubes placed below the triangle.

The lateral approach has its own trade-off. A trauma center comparison of approaches (Huber-Wagner, 2007) found interlobar (fissural) placement significantly more often with lateral tubes than anterior ones. Clinically relevant malfunction was similar between the two, and the authors judged both approaches justified.

Chest Tube Equipment

Set up everything before you open the skin. This checklist follows Merck’s equipment list for open tube thoracostomy:

Item	Notes
Sterile barrier supplies
Antiseptic skin prep
Local anesthetic, needles, syringes	For skin, tissue, periosteum and parietal pleura
Size 11 scalpel
Hemostats or Kelly clamps	For blunt dissection and clamping the tube
Chest tube, 16–36 Fr	Size by indication (table above)
Nonabsorbable suture	To secure the tube
Petroleum gauze and occlusive dressing
Water seal drainage apparatus	Connected to suction and ready before insertion

For a catheter thoracostomy, Merck uses a 14 Fr or smaller pigtail kit plus the same supplies minus the chest tube. Your department’s tube and drainage system are what you’ll actually use, so know which ones you stock.

How to Insert a Chest Tube: Step by Step

These steps follow the open blunt-dissection technique described by Merck and by the 2014 review. Adapt them to your institution’s protocol.

1. Connect the water seal apparatus to suction and set it aside.
2. Position the patient with the head of the bed raised 30–60° and the arm on the affected side abducted, hand behind the head.
3. Mark the site in the triangle of safety, then prep and drape.
4. Infiltrate local anesthetic into the skin, subcutaneous tissue, rib periosteum and parietal pleura, aspirating as you advance.
5. Confirm pleural entry by aspirating air or fluid into the anesthetic syringe.
6. Estimate how deep the tube must go so that every side hole sits inside the pleural space.
7. Make a 1.5–2 cm skin incision parallel to the rib.
8. Bluntly dissect with a clamp over the upper edge of the rib down to the pleura.
9. Enter the pleural space with the clamp, keeping it over the rib.
10. Insert a finger into the pleural space to confirm entry and sweep for adhesions.
11. Clamp the tube at both ends and guide it in, directing it apically for pneumothorax or inferoposteriorly for fluid.
12. Check for fogging in the tube, swing of the fluid level with respiration, bubbling with a cough, or fluid drainage.
13. Suture the tube to the chest wall, apply petroleum gauze and an occlusive dressing, and tape it securely.
14. Connect the tube to the drainage system and get a chest x-ray.

Three warnings from Merck sit behind these steps. Lock the stretcher, because the force involved can move it. Under-anesthetizing and making the incision too small are the common insertion errors. If the tube ends up too shallow, replace it instead of pushing it in, since advancing it carries non-sterile tubing into the chest.

Avoid the trocar. A prospective CT study in critically ill patients (Remérand, 2007) found that trocar use was the only factor that predicted malposition, and the 2014 review links trocars with a higher rate of intrathoracic organ injury.

Seldinger (Pigtail) Technique

Small-bore catheters (14 Fr or smaller) go in over a wire. Merck describes the sequence:

1. Advance the introducer needle over the upper border of the rib while aspirating.
2. Pass the guidewire through the needle into the pleural space and remove the needle.
3. Nick the skin and pass the dilator over the wire.
4. Thread the catheter over the guidewire.
5. Confirm the last side hole lies within the pleural space, then remove the trocar and guidewire.
6. Secure, dress and connect the catheter as for a standard tube.

	Open (blunt dissection) chest tube	Seldinger pigtail catheter
Typical size	16–36 Fr	14 Fr or smaller
Pleural entry	Clamp and finger	Needle, wire and dilator
Where the evidence sits	Used for every indication in Merck; pigtail trials excluded patients in extremis	Stable traumatic pneumothorax and hemothorax (Kulvatunyou 2014, 2021)
Caution	Pain, larger incision	Can clog with clot in bloody effusions (Merck)

Connecting the Drainage System: Water Seal vs Suction

A chest tube must drain into a one-way system: suction, water seal without suction, or a Heimlich valve. The common commercial device has three chambers, described in the 2014 review: a collection chamber, a water seal chamber that also shows the air leak, and a suction control chamber connected to wall suction.

Keep the apparatus low. Merck specifies 100 cm (40 inches) below the patient to prevent backflow into the pleural space.

When suction is used, the 2014 review states that a low-level vacuum of 5–20 cm H2O is recommended in most cases. The same review found no evidence supporting routine initial suction in spontaneous pneumothorax, and cites trials after lung resection that favor early conversion to water seal for small to moderate air leaks.

Large-volume drainage is a judgment call. Merck notes that some clinicians cap drainage at 1.5 L in 24 hours to lower the risk of re-expansion pulmonary edema, but that the evidence doesn’t clearly tie the risk to volume.

Chest Tube Complications and What to Do

Complications are common and have not fallen over time. A 2018 meta-analysis of bedside tube thoracostomy (22 Fr or larger) in trauma patients pooled 29 studies and 4,981 tubes and found a median complication rate of 19% (95% CI 14–24.3). Positional problems made up 53.1% of those complications, followed by removal (16.2%), insertional (15.3%) and infection-related (14.8%).

Malposition

Malposition is common and easy to miss on the first film. In the Remérand CT study, 30% of percutaneously inserted tubes in critically ill patients were malpositioned: 21% in a fissure and 9% in lung parenchyma.

A supine AP film misses many of these. In a review of resident-placed chest tubes at a regional trauma center (Ball, 2007), 6 of 11 positional and intraparenchymal placements were occult on the post-insertion supine AP x-ray. A radiology study of malpositioned tubes (Lim, 2005) found CT identified 28 malpositioned tubes among 76, while frontal radiographs identified only 6. If position or function is in doubt, Merck recommends PA and lateral films or CT.

Other complications

Merck lists these, along with malposition:

• Blockage from clot, debris or kinking, and dislodgement that requires replacement
• Bleeding, including intercostal vessel injury
• Infection of residual fluid or the insertion site
• Re-expansion pulmonary edema
• Subcutaneous emphysema
• Lung or diaphragm laceration, and intercostal neuralgia
• Rarely, injury to other thoracic or abdominal organs

A blocked tube shows no fluctuation of the fluid column with breathing or coughing, according to the 2014 review, and an ongoing air leak behind a blocked tube can produce a tension pneumothorax.

Antibiotic prophylaxis in trauma

The evidence now leans toward giving it. The EAST antibiotic prophylaxis guideline (Freeman, 2022) found that prophylaxis lowered empyema rates (OR 0.47, 95% CI 0.25–0.86), with a larger effect after penetrating injury, and no effect on pneumonia or mortality. It conditionally recommends antibiotics at the time of insertion in adult trauma patients.

Keeping the Skill When You Rarely Place One

Training sets a low floor. The ACGME key index procedure minimums (2017) require 10 chest tubes across an entire emergency medicine residency. After residency, how often you place one depends on your setting.

Operator factors show up in the complication data. In the Ball review, 17 complications occurred in 76 resident-placed tubes. Nonsurgical resident operators and placement outside the trauma bay independently predicted complications, and rates by training discipline ranged from 7% in general surgery to 40% in emergency medicine, from small numbers at a single center.

Deliberate practice can hold at least part of the skill. In a chest tube securement study (Ruparel, 2017), 19 emergency medicine residents completed a 45-minute session on a simulator costing about $5. Their securement scores improved, and at 3-month retention testing on a cadaver they did not differ significantly from the immediate post-test. That is one component of the procedure, measured on cadavers, and it doesn’t show an effect on patients, which is consistent with what the literature says about simulation and patient outcomes.

The broader problem of procedural skill decay is the subject of one of our podcast episodes, and our episode on learning curves and competency covers learning curves for intubation. Short, repeated rehearsal is one practical option for a procedure you can’t schedule. That is how the monthly practice sessions work in SimKit: about 30 minutes a session, with tube thoracostomy revisited three times a year on models you keep. Practice like this supports retention and confidence. It doesn’t replace supervised experience or your institution’s credentialing.

Chest Tube FAQ

What size chest tube do you use for a pneumothorax?

Merck lists 20–24 Fr for pneumothorax, and a randomized trial found a 14 Fr pigtail worked as well as a 28 Fr tube for uncomplicated traumatic pneumothorax, with less pain (Kulvatunyou 2014).

Where is a chest tube placed?

In the triangle of safety, usually the 4th or 5th intercostal space between the anterior and midaxillary lines, passing over the upper edge of the rib.

Is a pigtail catheter as good as a chest tube for hemothorax?

In hemodynamically stable trauma patients, a multicenter trial found similar failure rates (11% vs 13%), and EAST conditionally recommends pigtails for this group. Unstable patients were excluded from that trial.

Does a chest tube go into the lung?

It shouldn’t; the tube belongs in the pleural space, and a tube in lung parenchyma is a malposition, found in 9% of tubes in one prospective CT study of critically ill patients (Remérand 2007).

Should a chest tube go to water seal or suction?

Merck uses either wall suction or gravity drainage depending on the case, and a 2014 review found no evidence for routine initial suction in spontaneous pneumothorax, recommending 5–20 cm H2O when suction is used.

How do you confirm chest tube placement?

Look for fogging, fluid swing with breathing, bubbling with a cough or fluid drainage, then get a chest x-ray. If position or function is in doubt, Merck recommends PA and lateral films or CT, since a supine AP film misses many malpositioned tubes.

The Bottom Line on Chest Tube Placement

Chest tube placement comes down to choosing the right tube for the patient in front of you and putting it inside the triangle of safety. Go over the upper edge of the rib and skip the trocar, then remember that a supine film can miss a malpositioned tube.

The harder part is being ready on the day you need it, months after the last one. Tube thoracostomy is one of the four procedures in SimKit’s 12-month Procedural Training Course.

References

1. Dezube R. How to do tube and catheter thoracostomy. Merck Manual Professional Edition. Reviewed May 2025. https://www.merckmanuals.com/professional/pulmonary-disorders/how-to-do-pulmonary-procedures/how-to-do-tube-and-catheter-thoracostomy
2. Sahota RJ, Sayad E. Tension pneumothorax. In: StatPearls [Internet]. StatPearls Publishing; 2025. Updated July 7, 2025. https://www.ncbi.nlm.nih.gov/books/NBK559090/
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15. Accreditation Council for Graduate Medical Education. Emergency Medicine Defined Key Index Procedure Minimums. November 2017. https://www.acgme.org/Portals/0/PFAssets/ProgramResources/EM_Key_Index_Procedure_Minimums_103117.pdf
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