Tube thoracostomy, open

Note: For teaching purposes, the video was recorded with the patient in the lateral recumbent position.

Make a 1- to 2 cm skin incision directly at the level of the rib - in the “safe triangle” between the lower aspect of the pectoralis major muscle, the anterior aspect of the latissimus dorsi muscle, and the mammillary line.

Tip: To avoid subcutaneous emphysema, make the skin incision just wide enough for the index finger which then can bluntly dissect the tissue and guide the tube into place.

After the skin incision, first bluntly dissect down to the rib using the scissors. Then continue dissecting  craniad at the upper aspect of the rib.

Tip: Tunneling through the soft tissues results in sliding layers thereby fashioning an airtight tunnel.

After dissecting the muscles with the scissors strictly along the superior aspect of the rib, the parietal pleura is reached. Bluntly open it either with the finger (as shown in the illustration) or tip of the scissors. If pleural attachments/adhesions are expected palpate the pleural space with the finger. 

Note: In patients with pneumothorax, the escaping air will make a “hissing” sound at this point; in patients with a hemothorax or pleural effusion, the fluid will drain.