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Indications / Contraindications
Indications
- Empyema — purulent pleural fluid (pus or positive Gram stain); 3 stages: exudative → fibrinopurulent → organized. Early drainage essential; delay increases loculation and surgical risk. Mortality reported with delayed drainage.
- Complicated parapneumonic effusion — pH <7.20, glucose <60 mg/dL, LDH >3× upper limit normal, or recurrent after thoracentesis.
- Pneumothorax — large (>25% or apex-to-cupula >3 cm) primary spontaneous PTX; any secondary spontaneous PTX; tension PTX after needle decompression; ventilated patients; traumatic; persistent/recurrent.
- Hemothorax — to guide management: surgical threshold >1000–1500 mL total, >300–500 mL first hour, or >100 mL/h × 3h.
- Malignant pleural effusion — recurrent symptomatic effusion after thoracentesis; may proceed to pleurodesis or tunneled PleurX catheter.
- Chylothorax — thoracic duct injury; drainage guides timing of thoracic duct ligation or lymphatic embolization.
- Postoperative — cardiothoracic and esophageal surgery drainage.
Contraindications
- Absolute: Lung completely adherent to chest wall throughout hemithorax (negated in hemodynamically unstable patient).
- Relative: SIR Category 1 — can safely proceed with INR <3.0, PLT ≥20,000; most anticoagulants do NOT need to be held.
- Overlying cellulitis or Herpes zoster infection at insertion site (choose alternate site).
- Avoid chest tube (prefer alternate therapy) for: CHF effusion (diuresis); hepatic hydrothorax (thoracentesis, TIPS, transplant); pneumothorax ex vacuo (conservative); trapped lung with effusion (decortication or IPC for palliation); endobronchial obstruction + effusion (treat obstruction); mediastinal emphysema (increase O₂, vent changes).
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Pre-Procedure Checklist
Review imaging. CT chest to characterize collection (free-flowing vs. loculated, position relative to diaphragm and fissures), identify complex/multifocal collections requiring multiple tubes, assess lung for trapped lung (contraindication to pleurodesis).
Labs (SIR Category 1). INR <3.0, PLT ≥20,000. Anticoagulants generally do NOT need to be held — meta-analysis of 5,000+ patients confirmed low bleeding risk without correction.
Pleural fluid characterization. Send for pH, glucose, LDH, protein, cell count + differential, Gram stain + culture, cytology if malignancy suspected. Light's criteria: exudate if: fluid:serum protein >0.5 OR fluid:serum LDH >0.6 OR fluid LDH >2/3 upper limit of serum LDH.
Antibiotics. Not routine for simple drainage. For empyema: start broad-spectrum IV antibiotics covering anaerobes, S. aureus, S. pneumoniae, H. influenzae, K. pneumoniae, E. coli before or concurrent with drainage.
Equipment. Select catheter size based on indication — 10–12 Fr for simple PTX or serous effusion; 14–18 Fr for empyema/hemothorax; 12–16 Fr pigtail for small loculated collections.
Sedation. Moderate sedation recommended. Parietal pleura is most pain-sensitive structure — ensure adequate lidocaine to parietal pleura. Post-insertion: bupivacaine 0.25% for extended pain relief.
Consent. Malposition (~30% in critically ill), intercostal artery injury, pneumothorax, reexpansion pulmonary edema (REPE), infection/empyema (from tube), tube dislodgement.
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Relevant Anatomy
Intercostal Anatomy
- VAN (from superior to inferior along inferior rib border): VEIN → ARTERY → NERVE — neurovascular bundle lies in costal groove along INFERIOR surface of rib.
- Enter SUPERIOR to rib to avoid VAN.
- CRITICAL EXCEPTION: Paravertebral/posterior intercostal space — posterior intercostal artery does NOT follow the costal groove near spine; it courses in the MID-INTERCOSTAL space. Older patients with tortuous vessels especially at risk.
- Posterior paravertebral access = higher bleeding risk even with "superior rib" approach.
- Internal thoracic artery/vein: Run 1–2 cm lateral to sternum; avoid anterior entries within 2 cm of sternal border.
▶ View VAN rule diagram
Intercostal VAN anatomy. The neurovascular bundle (V→A→N) runs in the costal groove along the inferior surface of each rib. Enter superior to the lower rib. Exception: posterior intercostal artery courses mid-intercostal near the spine.
Tube Positioning by Pathology
- Pleural fluid (gravity-dependent): Enter posterolateral at 4th–5th ICS posterior axillary line; orient tube posteroinferiorly. In supine patient, fluid collects posteriorly. Guide tip toward spine on AP fluoro, confirm stays close to spine on oblique view.
- Pneumothorax (non-dependent): Enter anteriorly at 2nd ICS midclavicular line OR anterior axillary line; orient tube toward apex. In supine patient, air collects anteriorly. Left anterior placement: confirm cardiac position on imaging first.
- Fissure/fissural loculation: CT guidance required; pigtail catheter often more appropriate than straight tube.
- Scapula: Avoid entry adjacent to inferior scapula — catheter will be displaced when patient adducts arm. Use entry point inferior or lateral to scapula.
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Technique
Default RadCall approach · share your own below
Supplies
Ultrasound + sterile probe cover
ChloraPrep
Sterile drape
1% lidocaine (anesthesia)
0.25% bupivacaine (post-insertion)
18g access needle
0.035" J-wire
Serial dilators
Pigtail chest tube (10–16 Fr)
#11 blade
0 silk suture × 2
Sterile dressing
Chest drainage system (Pleur-evac or equivalent)
Suction tubing
Steps
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Position and planning
Position patient supine; abduct ipsilateral arm to displace scapula superiorly. For posterolateral access, mild contralateral tilt improves workspace. Use CT or CXR to plan trajectory. US survey to confirm collection, assess depth, identify diaphragm. Count ribs from angle of Louis (manubriosternal junction = 2nd rib). For fluid: plan entry posterior axillary line 4th–5th ICS. For PTX: plan entry anterior axillary or midclavicular 2nd ICS.
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Prep, drape, and anesthesia
ChloraPrep prep. Sterile drape. Moderate IV sedation. Anesthetize skin to parietal pleura with 1% lidocaine using 22g needle. Generously anesthetize parietal pleura (most pain-sensitive layer) — inject while confirming fluid or air return. Post-insertion: instill 5–10 mL bupivacaine 0.25% via catheter for extended pain control.
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Access
Attach 18g needle to syringe with gentle negative pressure. Advance SUPERIOR to rib with real-time US guidance. Confirm fluid or air return. For equivocal location: cone beam CT may clarify guidewire position in pleural space vs. lung parenchyma vs. extrapleural.
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Guidewire placement
Remove syringe; insert 0.035" J-wire. Advance under fluoroscopy. Wire should move freely through pleural space (low resistance). Limited wire mobility = loculated space or lung parenchyma → choose different access site. Confirm wire position under fluoro (should parallel chest wall, not course into lung).
▶ View guidewire in pleural space
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Serial dilation
Serial dilate over wire through intercostal space. Firm, rotating motion. Small 3–5 mm skin nick if resistance. Do NOT over-dilate — only enough for catheter.
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Catheter placement
Thread pigtail catheter over wire. For fluid: advance tip posteriorly and inferiorly. For PTX: direct apically. Remove wire; pigtail locks in place (or straight tube secured with suture). Connect to drainage system.
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Connect and confirm
Connect to 3-chamber water seal device (Pleur-evac). Apply -20 cm H₂O suction in most patients (dry valve: up to -40 cmH₂O; wet column: up to -25 cmH₂O). Fluid should flow freely; PTX should show bubbling. If only aspiratable with syringe (not free flow), reposition. Suture with 0 silk × 2. Transparent dressing. Secure tubing with omental tape or FLEXI-TRAK.
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Post-placement CXR
Obtain immediately. Confirm tube within pleural space. Intrafissural, intraparenchymal, mediastinal, or extrapleural placement = malposition → reposition. All drainage holes must be within pleural space (radiopaque marker at most proximal hole).
▶ View post-placement CXR
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Troubleshooting
Problem
No fluid drainage after placement
Cause: Tube in fissure, kink, loculation, evacuated collection.
Fix: Confirm with CXR; check for tube kink (visual inspection); flush with 10 mL NS; exchange for larger tube or repositioning under fluoro; CT to assess residual collection.
Problem
No tidal fluctuation in water seal
Cause: Tube kinked/occluded, complete lung expansion (normal), tube displaced.
Fix: Confirm kink with CXR; ask patient to cough — if bubbling, air leak present. If no fluctuation + no lung expansion on CXR: obstruction. Flush with saline; if tube blocked → exchange.
Problem
Persistent air leak (>5–7 days)
Cause: Bronchopleural fistula (communication between airways and pleural space).
Fix: Increase suction to improve pleural apposition. If suction is perpetuating fistula (aggressive drainage keeping it open): trial water seal. Persistent BPF → thoracic surgery consultation. Blood patch or intrabronchial valve may be attempted.
Problem
Loculated empyema not draining
Cause: Fibrin septations preventing drainage through single catheter.
Fix: tPA + DNase combination therapy (tPA 4–6 mg + DNase 5 mg in 50 mL NS instilled q12h, clamp 2h, × 3 days = 6 doses total; stop if bleeding from tube). Two chest tubes for large multiloculated collections. VATS if tPA/DNase fails.
Problem
Reexpansion pulmonary edema (REPE)
Cause: Rapid drainage of large chronic effusion; especially long-standing collapse >3 days. Recognition: Cough, chest tightness, hypoxemia, frothy secretions within 1–2h of drainage; CXR shows unilateral pulmonary edema.
Fix: STOP drainage; clamp tube. Supportive care: supplemental O₂, positive pressure ventilation if severe. Limit initial drainage to 1000–1500 mL; clamp for 1–2h before resuming.
Problem
Subcutaneous emphysema
Cause: Side holes of tube outside pleural space; large PTX not fully evacuated.
Fix: CXR to confirm tube position; if side holes outside pleura → reposition/exchange. Consider larger caliber tube or second tube for large PTX.
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Complications
Immediate
- Malposition (up to 30% in critically ill, most common with non-image guided): intrafissural (impairs drainage), intraparenchymal (risk of abscess, hemothorax), extrapleural (subcutaneous emphysema), mediastinal (surgical consult before repositioning).
- Intercostal artery injury (<1% with IR-guided): can cause hemothorax requiring TAE; recognized by unexpected hemothorax post-insertion; CE-CT to localize; TAE as primary treatment.
- Organ laceration: spleen (left), liver (right), diaphragm (low entry) — rare with image guidance.
- Pneumothorax from tube insertion into effusion: usually small; managed with existing tube.
Delayed
- Reexpansion pulmonary edema (REPE) (<1% but life-threatening): rapid drainage of large chronic effusion; limit to 1000–1500 mL initially.
- Empyema (tube-related): rare with sterile technique (~0.2% with IR-guided).
- Bronchopleural fistula: persistent air leak suggesting epithelialization of pleural-airway communication; thoracic surgery referral if persistent >5–7 days.
- Tube dislodgement: anchor securely; remove pigtail retention string for easier bedside removal if non-IR team removing.
- Tube obstruction: kink or clot; flush with NS daily; exchange if persistent.
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Post-Procedure
Daily Assessment
- Vital signs + oximetry daily; chest tube output volume and appearance q8h.
- Water seal chamber: confirm tidal fluctuation with respiration (indicates patent tube in pleural space). No fluctuation = complete drainage OR obstruction.
- Ask patient to cough: bubbling in water seal = active air leak (bronchopleural fistula). Do NOT remove tube if air leak present.
- Auscultation: breath sounds; palpate for subcutaneous emphysema. Inspect exit site for infection, dressing integrity, tube kinking.
Removal Criteria
- Pleural effusion/empyema: Output <200 mL/day; serous-appearing drainage; CXR shows complete drainage; CT confirms if equivocal. Higher thresholds (up to 500 mL/day) used by some; lower threshold (200 mL/day) reduces readmission rate.
- Pneumothorax: No air leak for 24h; no pneumothorax on water seal trial (transition from suction → water seal → observe 4–6h). Brief water seal trial preferred; clamping trial NOT recommended (unnecessary risk of tension PTX). Removal on suction acceptable if criteria met.
- Removal technique: IV narcotic 5–10 min before removal. Remove during end-expiration/Valsalva (minimizes atmospheric pressure gradient). Rapidly cover site with petroleum gauze. Suture closure rarely needed unless large incision.
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Critical Pearls
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Enter SUPERIOR to rib — VAN bundle runs in costal groove at inferior rib surface. EXCEPTION: paravertebral access — posterior intercostal artery runs mid-intercostal space near spine in older patients.
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1000–1500 mL initial drainage limit — prevent reexpansion pulmonary edema (REPE); clamp tube for 1–2h before resuming. Patient coughing or chest tightness = stop draining.
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For PTX: anterior; for fluid: posterior — air collects anteriorly in supine patients; fluid collects posteriorly. Wrong positioning = tube fails to drain.
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Avoid major fissure placement — intrafissural tube impairs both air and fluid drainage; use CT guidance for any fissure-adjacent collection.
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tPA + DNase (not tPA alone) — MIST2 trial: combination tPA 4–6 mg + DNase 5 mg q12h × 3d dramatically improves loculated empyema outcomes; tPA or DNase alone is ineffective.
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Trapped lung ≠ treat with chest tube — inability to expand because of visceral peel; chest tube will just create a chronic air leak. Consider decortication or IPC for palliation.
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Don't remove tube with active air leak — even without visible PTX on CXR; bubbling in water seal during cough = bronchopleural fistula still present; removing tube risks tension PTX.
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Subclavian space is shared with phrenic nerve — high subclavian entries risk phrenic nerve injury; aim for 4th–6th ICS range.
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Drainage System & Pleurodesis
Three-Chamber Water Seal System
- Collection chamber: collects drained fluid; graduated for output measurement. Mark level q8h.
- Water seal chamber: one-way valve preventing air re-entry to pleural space. Should contain 2 cm water. Tidal fluctuation with breathing = patent tube. Bubbling = active air leak.
- Suction control chamber: wet column (H₂O, up to -25 cmH₂O) or dry valve (up to -40 cmH₂O). Wall suction must be kept at ≥-80 mmHg (>108 cmH₂O) to deliver desired suction. Typical setting: -20 cmH₂O.
- Heimlich valve: portable one-way flutter valve; enables ambulation; suctionless passive drainage only; for small PTX in ambulatory patients.
▶ View water seal system diagram
Click image to enlargeThree-chamber water seal system (Atrium-type). ① Collection — graduated fluid measurement. ② Water seal — 2 cm H₂O one-way valve; tidal fluctuation indicates patent tube. ③ Suction control — 20 cm H₂O standard; gentle bubbling confirms active suction.
Troubleshooting the Drainage System
- Collection chamber full: fluid stops draining → change CTDS immediately.
- Chest tube wrapped/twisted by ambulatory patient: untwist tubing before troubleshooting tube position.
- Air bubbling stops: lung reexpanded (check CXR) OR tube/system disconnected (inspect all connections) OR tube occluded.
- Subcutaneous emphysema increasing: side holes outside pleura OR air not adequately evacuated → exchange/reposition.
Chemical Pleurodesis (Talc Slurry)
- Indications: Recurrent malignant effusion, secondary spontaneous PTX, recurrent primary PTX.
- Prerequisites: Complete lung expansion on CXR (trapped lung = pleurodesis failure); pH >7.2 (low pH predicts failure); no active infection.
- Technique: Conscious sedation + 20 mL bupivacaine 0.25% instilled intrapleurally to anesthetize pleura. Instill well-agitated suspension of 5 g talc in 100 mL sterile NS. Clamp tube 1–2h. Rotate patient positions (some advocate). Unclamp and return to suction. Follow removal criteria.
- Expected: Chest pain and fever for 24–48h (pleural inflammation = desired effect). Monitor for ARDS (rare, dose-dependent with fine-particle talc). Talc success rate 70–100%.
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References & Resources
Primary sources · Key data · Related procedures
Key Guidelines
- BTS guidelines for the management of pleural infection (2010)
- ACCP Consensus Statement: Management of Malignant Pleural Effusion
Primary References
- Davies HE, Davies RJ, Davies CW; BTS Pleural Disease Guideline Group. Management of pleural infection in adults: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65(Suppl 2):ii41–53.
- Kearney SE, Davies CW, Davies RJ, Gleeson FV. Computed tomography and ultrasound in parapneumonic effusions and empyema. Clin Radiol. 2000;55(7):542–547.
- Caplan DM, Kim DH, Afnan JH, et al. Empyema: analysis of treatment outcomes and identification of factors predicting treatment success and failure. J Vasc Interv Radiol. 2021;32(9):1316–1324.