THORACOSTOMY  (CHEST  TUBE)

1. Indications:
• Pneumothorax >10%.
• Hemothorax. This will be visible when >300 ml of blood is present in pleural cavity.
• Empyema
• Chylothorax
   
2. Technique:
    
1. Prep anterolateral chest wall with iodine solution.
    
2. Incision should be at anterior-mid axillary line at level of 4th-5th intercostal spaces.
    
3. Inject local anesthetic.  Make incision at IC level 4-5 (nipple level),  or by pulling the skin up to the level of  IC line 3-4 to create a "tunnel" and a better anchorage of the chest tube.
    
4. The incision is carried parallel to the rib and  should be about 1 inch long. Dissect bluntly until the rib is reached.
    
5. Using Kelly clamps, spread the IC muscles while applying constant pressure in order to puncture the pleura.
    
6. When in pleural cavity, sweep with a finger. Assess for adhesions.  If none, tube held with Kelly clamp is inserted into pleural cavity and directed anteriorly (for pneumothorax) or posteriorly (for hemothorax) until the last hole is within thoracic cavity.
    
7. Connect to pleurovac.
    
8. Suture the chest tube in place and apply dressing.

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