Indications
Emergency
Pneumothorax
-In all patients on mechanical ventilation
-When pneumothorax is large
-In a clinically unstable patient
-For tension pneumothorax after needle decompression
-When pneumothorax is recurrent or persistent
-When pneumothorax is secondary to chest trauma
-When pneumothorax is iatrogenic, if large and clinically significant
Hemopneumothorax
Esophageal rupture with gastric leak into pleural space

Non emergency
Malignant pleural effusion
Treatment with sclerosing agents or pleurodesis
Recurrent pleural effusion
Parapneumonic effusion or empyema
Chylothorax
Postoperative care (e.g., after coronary bypass, thoracotomy, or lobectomy)

Contraindications
- when a lung is completely adherent to the chest wall throughout the hemithorax
- a risk of bleeding in patients taking anticoagulant medication or in patients with a predisposition to bleeding or abnormal clotting profiles


Procedure
Preperation
-Patient in supine position
-Maximally abduct the ipsilateral arm or place behind head.
-The area for incision is 4th to 5th intercostal space in the anterior axillary line at the horizontal level of the nipple.
-Triangle of safety: Ant border of lat dorsi, lat border of pectoralis major muscle, the apex just below the axilla and a line above the horizontal level of the nipple.
-Ensure sterile field is created.
-Use LA for deeper subcut tissue & intercostal muscles and periosteal surface & parietal pleura. (lidocaine)

Incision
-Incise 1.5-2cm parallel to rib
-Cut through subcut layers & intercostal muscles
-Path should transverse diagonally up toward the next superior intercostal space. Push thru the paretal pleura, you may also digitally penetrate the pleura to avoid puncturing lung tissue, using your index finger to explore and palpate within the pleural layer & ensure the lung falls away from the pleura. If it does not, this may show e presence of an adhension.

Tube Insertion
-Once the distal tip of the tube has passed through the incision, unclamp the Kelly
clamps or forceps & advance the tube.
-Aim the tube apically for evacuation of a pneumothorax and basally for evacuation of any fluid.

Securing the Tube
-Sutures should be used on both sides of the incision to close the ends.
-Use the loose ends of the sutures to wrap around the tube and tie them off
-Tape the tube to the side of the patient & wrap gauze dressing & multiple pressure dressings around the tube.
[Purse-string sutures are not recommended owing to poor cosmetic results and increased risk of skin necrosis; the seal they provide does not prevent air leaks.]
-Connect the distal end of the chest tube to a sterile pleural drainage system,unclamp
the distal end; Do not reclamp the chest tube, once released, may lead to the redevelopment of a pneumothorax and may create a tension pneumothorax.

Chest Radiograph Confirmation
-AP chest radiograph to confirm placement,If the proximal drainage hole is outside the pleural space,drainage may be ineffective and an air leak may result. In this circumstance, remove & a new chest tube inserted.

Complications
-bleeding and hemothorax due to intercostal artery perforation
-perforation of visceral organs (lung, heart, diaphragm, or intraabdominal organs)
-perforation of major vascular structures such as the aorta or subclavian vessels
-intercostal neuralgia due to trauma of neurovascular bundles,
-subcutaneous emphysema
-reexpansion pulmonary edema
-infection
-pneumonia
-empyema.

I shall not talk about chest-tube removals.. haha I will bore you guys to death:)

Source: NEJM