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Key Points

  • Do not confuse a pulmonary bleb or bullae for a pneumothorax.

  • The neurovascular bundle runs inferior to each rib. Always enter the thoracic cavity over the rib, never under.

  • Never advance or replace a tube that has migrated out of the chest. Always place a new one.


Needle thoracostomy is indicated for emergent decompression of suspected tension pneumothorax. Tube thoracotomy is indicated after needle thoracostomy, for simple pneumothorax, traumatic hemothorax, or large pleural effusions with evidence of respiratory compromise.


A pneumothorax on chest x-ray may be confused with a pulmonary bleb or bullae. Bullae and blebs are large gas-filled spaces with thin walls where pulmonary parenchyma has been destroyed, therefore greatly increasing alveolar size and mimicking pneumothorax. These are frequently located in the lung apices and are often seen in patients with severe chronic obstructive pulmonary disease. It is essential to confirm the presence of a pneumothorax before placement of a thoracostomy tube. See Chapter 24 for further clinical scenarios in which tube thoracostomy can be substituted for less invasive or conservative management of pneumothoraces.


Needle thoracostomy requires a 12- to 16-gauge angiocatheter, 3 to 4.5 inches in length, and a 5–10 mL syringe. Tube thoracostomy requires a 36- to 40-F tube for hemothorax in adults or 20- to 24-F tube in children. For a simple pneumothorax, an 18- to 28-F tube in adults or 14- to 16-F tube in children is sufficient. Additional supplies required for tube thoracostomy placement include povidone-iodine (Betadine) solution, sterile drapes, sterile gloves, 20 mL of 1% lidocaine with epinephrine, scalpel with #10 blade, large curved and straight clamps, a needle driver, 2-0 silk suture, and a commercial or 3-bottle suction apparatus.


Needle thoracostomy is accomplished by cleansing the skin in the upper chest and inserting the catheter over needle into the second intercostal space (just over the third rib) at the midclavicular line. Tension pneumothorax is confirmed with a sudden rush of air followed by improvement in the patient's vital signs. Tube thoracostomy placement should follow this procedure.

Tube thoracostomy is performed by first positioning the patient with the arm of the affected side above the patient's head and securing it with a soft restraint. The chest wall is prepared with povidone-iodine solution and a sterile field in the area of the fourth intercostal space (below the fourth rib) at the mid to anterior axillary line. The skin is then anesthetized with lidocaine, followed by anesthesia of the deeper structures tunneling above the fifth rib. Next, inject the intercostal muscles of the fourth to fifth intercostal space, extending into the parietal pleura. Additionally, procedural sedation or intercostal nerve blocks may be used. After adequate anesthesia, a 2- to 3-cm incision is made at the fifth ...

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