Written by Alex Clark
Pleural cavity decompression via surgical tube thoracostomy or pleural catheter (pigtail) is a core EM skill. This excellent, high-yield review gets you ready.
Totally tubular, dude
Indications & Contraindications
- Indications: Pneumothorax, PTX (spontaneous/traumatic), hemothorax, pleural effusion.
- Relative contraindications: Overlying cellulitis, coagulopathy (INR >1.5—but do not delay if emergent), or complex anatomy (adhesions, blebs—consider CT before and/or cautious finger sweep during).
- No absolute contraindications.
Thoracostomy Options
- Tube sizes: Small (7–14 Fr), Medium (16–22 Fr), Large (>24 Fr).
- Tension PTX = emergent decompression:
- Needle the 4th/5th intercostal space (ICS), anterior axillary line or do finger thoracostomy (my preferred), then definitive tube or pleural catheter.
- Pleural catheters (aka pigtails): Seldinger-based, pigtail-type catheters; less invasive, lower pain, shorter duration, possibly slower drainage.
- Size selection:
- Primary (spontaneous) and traumatic PTX: Small-bore = large-bore efficacy, with fewer tube days.
- Traumatic HTX: Recent studies support ≤14 Fr equivalence to 28–32 Fr; ATLS still recommends larger—follow local policy.
- Large tubes may reduce risk of obstruction if: recurrent PTX, bronchopleural fistulas, or complex effusions/adhesions.
Procedure Preparation
- Location: Triangle of safety (above 5th ICS, anterior/mid-axillary line, superior rib border). For apical PTX, pleural catheter at 2nd ICS midclavicular line may be considered.
- Ultrasound: Confirm diaphragm, map intercostal artery (color Doppler), identify lung point or effusion, confirm intrathoracic entry.
- Positioning & setup: Supine, semi-recumbent 45°, ipsilateral arm flexed/abducted; generous local anesthesia ± regional block and/or procedural sedation; ensure equipment and drainage system ready pre-insertion.
Surgical Thoracostomy Technique
- See Table 1 for summarized steps.
- Pearls:
- 360° finger sweep before tube insertion.
- If tube resists prior to last fenestration, it’s likely in a fissure or parenchyma—withdraw slightly, rotate, and re-insert.
- To assess kinking: rotate tube 180°—if it springs back, it’s kinked.
- For patients with excess soft tissue, modified Seldinger technique with bougie may facilitate entry.
- Direct tube posterior-superiorly to optimize air/fluid evacuation.
Pleural Catheter Technique
- See Table 2 for summarized steps.
- Seldinger Technique: aspirate air/fluid → wire → incision → dilator/introducer → catheter advanced until all fenestrations within pleural space.
- Attach 3-way stopcock and suction, secure without occluding tube lumen, apply occlusive dressing.
Thoracostomy Tube Drainage Systems
- Types: Three-chamber (collection, water seal, suction) or one-way Heimlich valve (ambulatory PTX).
- Troubleshooting:
- Continuous bubbling = air leak.
- Absent tidaling (vertical fluid movement with respiration) = lung re-expanded or tube obstructed.
- Keep system upright and below chest level.
- Gravity vs. suction: Gravity (water-seal) often sufficient for pleural drainage after initial suction; continue suction for persistent air leak (although in my experience may paradoxically worsen in bronchopleural fistula) or for heavy effusion burden.
Complications (Full list in Table 3)
- Tube malposition: Most common. Leave if draining; replace if external or nonfunctional.
- Nonfunctioning tube: Check for obstruction or suction failure; avoid milking/stripping.
- Serious complications: Intercostal bleed, pulmonary laceration/infarction, or injury to mediastinal/extra-thoracic structures → surgical consult.
- Re-expansion pulmonary edema: Avoid >1L rapid effusion drainage (although RPE may be more related to increased negative pressure & trapped lung; watch for chest pain during); treat hypoxemic respiratory failure with NIPPV.
- Infection prevention: Single-dose cefazolin/ceftriaxone for trauma may reduce empyema/pneumonia risk.
How does this change my practice?
The authors provide a comprehensive overview of all things thoracostomy. I highly recommend taking 30 minutes to read the full article.
Practice-ready takeaways…
- Unstable/Tension? Finger thoracostomy (+ surgical tube)
- Bigger (surgical tube) is better? Only in complex parenchymal disease (bullae & adhesions), recurrent effusion/PTX, suspected empyema w/ sonographic complexity
- Everything else? Pleural catheter (≤14 Fr)
- Apical PTX on mechanical ventilation? Don’t forget midclavicular line, 2nd ICS approach
- Subcutaneous tissue in your way? Next time try the bougie
Source
Tube Thoracostomy and Pleural Catheters: A Review for Emergency Clinicians. J Emerg Med. 2025 Oct;77:100-116. doi: 10.1016/j.jemermed.2025.07.053. Epub 2025 Aug 5. PMID: 40896901.
