The abnormal accumulation of air (pneumothorax), blood (hemothorax), fluid (pleural effusion), chyle (chylothorax) or pus (empyema) in the pleural space.^[1] The exact size or volume of each of these is dependent on the condition itself and the stability of the patient.

Pneumothorax (PTX) is the disease process with the most clearly outlined indications for tube thoracostomy. Any patient with unstable vital signs, severe breathlessness, or indications of or impending tension physiology should be decompressed immediately. For more stable patients, the American College of Chest Physicians (CHEST) as well as the British Thoracic Society (BTS) have created guidelines for chest tube (CT) insertion.^[2][3] To understand these, we need to first offer a few definitions:

​a. Spontaneous PTX: Not related to trauma or other (i.e. iatrogenic) cause.

b. Primary Spontaneous PTX: No apparent underlying lung disease or other diseases that promote PTX development.

c. Secondary Spontaneous PTX: PTX occurring in the setting of clinically apparent underlying lung disease such as chronic obstructive pulmonary disease (COPD).

​With these definitions in mind, here are the two societal recommendations by cause and size of PTX.

​Note: The tubes placed for these spontaneous PTXs are typically small (14 F catheter, often a pigtail, or a 16-22 F chest tube).

Insert your index finger along your Kelly into the pleural space. With your finger in place, remove your Kellys. Many recommend a finger sweep at this point, where the index finger is swept in a 360 degree fashion to assess for pleural adhesions. Care should be taken in cases of broken ribs to avoid injury to the operator. After this, the tube may be advanced. Depending on the size and flexibility of your tube, you may be able to pass it without any instrument assistance. Pay careful attention to insert the appropriate end (the end with the drainage holes on the side). Slide the tube along the palmar aspect of your hand and index finger to confirm entry into the pleural space. The tube should pass with little resistance. Avoid forcing as this is likely to create false tracts in the tissue planes. Direct the tube superiorly, medially, and posteriorly; rotate the tube 360 degrees during insertion to avoid kinking. Insert until at least all of the drainage holes are into the pleural space, then at least an additional 2 cm to accommodate for movement or sliding.^[8]

Note: If the tube is too small and/or flexible, clamp your Kelly onto the tube so that the tip of the Kelly is 1 cm from the tip of the tube. Clamp at an angle close to parallel. Slide the tube and Kelly along your palm and index finger into the pleural hole.