Jeffrey A. Claridge

Introduction

The most common indications for placement of a chest tube are pneumothorax (simple or tension), hemothorax, hemopneumothorax, empyema, and pleural effusion (acute or chronic). A chest tube needs to be placed in three defined situations. In the urgent situation the patient has unstable physiologic parameters and requires immediate chest tube placement. In the semiurgent situation the mandatory chest tube is needed “sooner rather than later,” and has an acute problem or indication but appears hemodynamically stable. However, delay in placing the chest tube could result in the patient becoming unstable and the need for an urgent procedure because of clinical deterioration. The nonurgent situation is typically elective and occurs in patients with stable hemodynamics and a chronic or recurrent physiologic problem. In other elective situations a chest tube is needed as part of a scheduled procedure, such as diaphragm repair or thoracotomy.

Superficial Anatomy and Topographic Landmarks

Regardless of the indication or urgency, five key anatomic concepts must be understood to maximize the effectiveness and safety of accessing the pleural space when placing a chest tube, as follows:

The first important concept of placing a chest tube or accessing the pleural space involves the ability to identify superficial anatomic landmarks (Fig. 43-1, A). The key landmarks for accessing the pleural space are identification of the clavicular head; midclavicular line; the anterior, middle, and posterior axillary lines; and intercostal spaces with corresponding ribs. The ability to count ribs accurately will facilitate the placement of chest tubes. In a female patient the nipple should not be used as a landmark. Instead, the inframammary fold should be used to identify the 5th rib at the anterior axillary line. In a male patient the lower border of the pectoralis major muscle is a good approximation for the site of tube insertion.