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  1. Evacuation of pneumothorax compromising ventilation and causing increased work of breathing, hypoxia, and increased PaCO2.

  2. Relieve tension pneumothorax causing respiratory compromise and decreased venous return to the heart, resulting in decreased cardiac output and hypotension. This is an emergency that should be handled by immediate needle aspiration before chest tube placement. (See Chapter 75.)

  3. Drainage of significant pleural fluid (pleural effusion, empyema, chylothorax, hemothorax, extravasation from a central venous line).

  4. Postsurgical drainage after repair of a tracheoesophageal fistula, bronchopleural fistula, esophageal atresia, or other thoracic procedure.


Prepackaged chest tube tray (typically includes sterile towels, gauze pads, 3–0 silk suture, a needle holder, curved hemostats, a no. 15 scalpel, scissors, antiseptic solution, antibiotic ointment, 1% lidocaine, 3-mL syringe, 25-gauge needle), sterile gloves, mask, eye protection, hat, gown, suction-drainage system (eg, Pleur-Evac system). A high-intensity fiberoptic light for transillumination or point-of-care ultrasound unit is helpful (see Chapter 44). Chest tube types and sizes are as follows:

  1. Standard (traditional) chest tube insertion. Requires a skin incision with blunt chest wall dissection and sutures. Use polyvinyl chloride chest tubes with or without trocars (8, 10, or 12F). Recommended chest tube size for weight: <2000 g, 8 or 10F; >2000 g, 12F.

  2. Percutaneous chest tube with pigtail catheter. Does not require a skin incision. The pigtail catheter is inserted through a needle. This is an easier and less invasive technique requiring less anesthesia. Disadvantages are that the catheter may kink and become obstructed since they are softer. Pigtail catheter sizes range from 5 to 12F, with 8 or 10F most commonly used.


  1. The site of skin insertion for the elective chest tube insertion is the same for both air and fluid, but the direction of the tube is determined by examining the anteroposterior (AP) and cross-table lateral or lateral decubitus chest films for air or fluid. Air collects in the uppermost areas of the chest, and fluid in the most dependent areas. For air collections, place the tube anteriorly. For fluid collections, place the tube posteriorly and laterally.

  2. Transillumination of the chest may help detect a pneumothorax but not a small pneumothorax (see Chapter 44). It can also document the success of air removal. With the room lights turned down, a strong light source is placed on the anterior chest wall above the nipple and in the axilla. The affected side usually appears hyperlucent (“lights up”) and radiates across the chest as compared with the unaffected side. Unless the infant’s status is rapidly deteriorating, a chest radiograph (both AP and lateral decubitus or cross-table lateral) should be obtained to confirm pneumothorax before the chest tube is inserted. If air is suspected, the infant should be lying on his or her side with the suspect side up; if fluid is suspected, the infant should be placed with the ...

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