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Emergency chest tube insertion treats tension pneumothorax, traumatic hemothorax, large-volume pleural effusion, and empyema. These conditions cause abnormal air or fluid accumulation in the pleural space, separating pleural layers and preventing lung expansion. The drainage relieves lung compression, enables lung re-expansion, and prevents mediastinal shift that reduces cardiac output.

Air accumulation in pneumothorax separates pleural layers, preventing lung expansion during respiration. Abnormal fluid in hemothorax or empyema uncouples the visceral pleura from the parietal pleura, disconnecting chest wall movement from lung movement and causing respiratory distress. Excessive pressure can also push the mediastinum away, reducing cardiac filling and output.

The preferred insertion site is the fourth or fifth intercostal space between the anterior axillary and mid-axillary line, typically at nipple level for the fifth space. The incision is made above and parallel to the fifth or sixth rib, protecting neurovascular bundles at the inferior rib aspect. This positioning reduces diaphragm injury risk and ensures proper pleural space access.

Insert a Kelly clamp into the incision and perform blunt dissection through subcutaneous tissue and intercostal muscles until firm resistance indicates the parietal pleura. Close the clamp, push it through the pleura into the pleural space, then open and spread it to create an opening. Sweep with a gloved finger to ensure no blockages, maintaining the opening's integrity while withdrawing the clamp.

Observe the tube for condensation and listen for air movement, which indicate correct positioning. Visible condensation and audible airflow confirm the tube is in the pleural space with all fenestrations properly located. Ask the patient to cough and observe for bubbles in the water seal chamber to ensure system patency. Order a chest X-ray to confirm final tube placement.

Chest tubes range from 12 to 42 French in size. Smaller sizes are reserved for pediatric patients, while 36 French or larger tubes are standard for hemothorax treatment and empyema drainage. Tubes consist of clear plastic with a radiopaque strip and fenestrations at the tip, allowing visualization on imaging and proper fluid drainage.

Common complications include local infection at the insertion site, subcutaneous emphysema from air leaking through excessive openings, and injuries to underlying organs like the lung and spleen. Tubes may dislodge, become blocked by clotted fluid, or be placed incorrectly in subcutaneous tissue or the abdomen, especially in obese patients where anatomical landmarks are misleading. Patients require constant monitoring with basic life support cardiopulmonary resuscitation and defibrillation readiness.