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An Urban Experience
enter the pleural space at the 7-9th intercostal space and terminate near the second rib.
A skin incision is made over the 11th intercostal space and the mid to dorsal third of the thorax, through the
skin approximately the diameter of the tube being used. The skin is either retracted cranially by an assistant, or large curved forceps are used to make a tunnel under the subcutaneous tissue or latissimus dorsi muscle to
the level of the 8-9th intercostal space. The forceps are pushed through the intercostal tissue and opened to establish a pathway that the thoracostomy tube with trocar can be fed through into the pleural space. Using
a trocar during placement keeps the tube stiff and facilitates placement into the cranial thorax. The tip of the trocar should never extend beyond the tip of the tube. The tube should be grasped with one hand at the distal end to prevent the tube from advancing too far to prevent accidental puncture of intrathoracic organs.
Once the thoracostomy tube is in the pleural space it
is directed into a cranial-ventral position, with the tip ending at the 2nd rib space. All side holes must be inside the pleural space. The trocar is removed and the tube
is secured by suturing to the periosteum of the rib, around the rib, or to the skin at the exit site. A second stabilizing suture is placed several inches from the insertion site in the skin and around the tube. The pleural space is evacuated either manually with a syringe or
by connection to a continuous drainage system. Post- placement radiographs are obtained. Having the distal tip all the way into the thoracic inlet can result in signi cant patient discomfort and it may be more comfortable if the tip of the tube is at the level of the second rib. A local bandage is placed with sterile gauze and transparent wound dressing or a more substantial bandage around the chest if additional wounds need to be covered.
The insertion site is inspected only if there is failure
to establish negative pressure, or there is excessive discharge. An Elizabethan collar is used to prevent premature removal. Potential complications include iatrogenic pneumothorax, intrathoracic organ puncture, and infection.
Pleural Catheter Placement
Pleural catheter (small bore, wire-guided chest drain) placement can be used for intermittent drainage with moderate to large volume, slow pleural expansion. A  exible pleural 10-14g catheter is placed unilaterally or bilaterally using a modi ed Seldinger technique. Having a larger diameter than a needle, this type of catheter permits more rapid removal of pleural contents with less restraint. This type of catheter is secured to the skin and allows repeated centesis over a short term (24-48 hours) without additional restraint. The Seldinger technique involves the placement of a catheter into the pleural space through which a j-wire is passed. The catheter
is removed while the j-wire is held in place. A dilator is placed over the j-wire and used to stretch the skin and body wall around the j-wire. The dilator is removed and the catheter placed over the j-wire into the pleural space. All the side holes should be within the pleural space.
The j-wire is then removed and the catheter is sutured in place. A local dressing is applied, and an Elizabethan collar used on the patient to prevent premature removal. Potential complication includes lung laceration and bleeding.
The pleural drainage tube is removed when the air leak appears sealed, and/or the  uid volumes have markedly decreased. Although a general rule is to keep the tube in place until only 1-2 ml/kg/d of  uid/air is removed, but the entire clinical picture is included in the assessment.
Available on request

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