Chest tube insertion is a common therapeutic procedure used to provide evacuation of abnormal collections of air or fluid from the pleural space. Tube thoracostomy may be indicated for pleural effusions associated with malignancy, infection, or hemothorax in the post-surgical setting. In these situations, drainage is imperative to allow for lung re-expansion. This protocol covers the task of chest tube placement by a Nurse Practitioner (NP).

Learning Sequence Builds Confidence

The learner practices the procedure in the ‘guided mode’ (ghosted hints, narrative from tutor) as often as they like. 

When the learner is confident that they can accurately demonstrate the procedure without error, the learner plays the level in the ‘expert mode’ (no hints or coaching narration) - which they can repeat as often as they wish. 

Finally, when the learner is confident that they have mastered the procedure - they take a one-time ‘exam’ attempt which results in their grade for that procedure.


Guided Mode - ghosted hints show step-by-step positions, learner can 'see through' the patient to verify placement.

Oculus Quest Hand Tracking - learner uses natural hand movements to interact (no need to memorize buttons & controls).

Oculus Quest Affordability & Ease of Use - next generation game development processes allow the untethered, mobile VR to present effective visual and interaction fidelity at 1/4 of the cost of desktop VR.

Physiology Engine - real-world patient & case data informs the simulation.

Feedback - Cloud-based enterprise incorporates real-time data acquisition that allows learner to track progress and mastery, and provides detailed insights for debrief with faculty.

Support - Enterprise incorporates Knowledge Base (with tutorial videos & FAQ) - combined with help desk support staff for learners and staff.




Demonstrate knowledge and technical skill of the following:

Medical indication and contraindications of chest tube insertion
Risks and benefits of the procedure
Related anatomy and physiology
Consent process (if applicable)
Steps in performing the procedure
Documentation of the procedure
Ability to interpret results and implications in management

Chest Tube Placement Checklist

  1. Wash hands and don personal protective equipment.
  2. Check platelet count and/or presence of coagulopathy. Consult with attending physician if platelet count is <50,000, or there is a known coagulopathy as to whether platelet transfusion or other intervention is needed prior to the procedure.
  3. Check patient history for hypersensitivity to the local anesthetic.
  4. Position patient in the sitting position with arms and head resting supported on a bedside adjustable table. If unable to sit, the patient should lie at the edge of the bed on the affected side with the ipsilateral arm over the head and the midaxillary line accessible for the insertion of the needle. Elevating the head of the bed to 30 degrees may help.
  5. Identify the insertion site, which is usually the fourth or fifth intercostal space in the mid-to-anterior axillary line (just lateral to the nipple in males), immediately behind the lateral edge of the pectoralis major muscle. Direct the tube as high and anteriorly as possible for a pneumothorax. For a hemothorax, the tube is usually inserted at the level of the nipple and directed posteriorly and laterally. Elevate the head of the bed 30 to 60 degrees, and place (and restrain) the arm on the affected side over the patient’s head. Do not direct the tube toward the mediastinum because contralateral pneumothorax may result. The diaphragm, liver, or spleen can be lacerated if the patient is not properly positioned or the tube is inserted too low.
  6. Assemble the suction-drain system according to manufacturer’s recommendations.
  7. Connect the suction system to a wall suction outlet. Adjust the suction as needed until a small, steady stream of bubbles is produced in the water column.
  8. Prep the skin with povidone-iodine or Chlorhexidine solution and allow to dry. Drape the site with fenestrated sheet. Using the 10 ml syringe and 25 gauge needle, raise a skin wheal at the incision area (in the interspace one rib below the interspace chosen for the pleural insertion) with 1% solution of Lidocaine with Epinephrine.
  9. Liberally infiltrate the subcutaneous tissue and intercostal muscles, including the tissue above the middle aspect of the inferior rib to the interspace where pleural entry will occur and down to the parietal pleura. Using the anesthetic needle and syringe, aspirate the pleural cavity, and check for the presence of fluid or air. If none is obtained, change the insertion site. Be careful to keep away from the inferior border of the rib to avoid the intercostal vessels.
  10. Make a 2 to 3 cm transverse incision through the skin and the subcutaneous tissues overlying the interspace. Extend the incision by blunt dissection with a Kelly clamp through the fascia toward the superior aspect of the rib above. After the superior border of the rib is reached, close and turn the Kelly clamp, and push it through the parietal pleura with steady, firm, and even pressure. Open the clamp widely, close it, and then withdraw it. Be careful to prevent the tip of the clamp from penetrating the lung, especially if no chest radiograph was obtained or if the x-ray film does not clearly show that the lung is retracted from the chest wall.
  11. Insert an index finger to verify that the pleural space, not the potential space between the pleura and chest wall, has been entered. Check for unanticipated findings, such as pleural adhesions, masses, or the diaphragm.
  12. Grasp the chest tube so that the tip of the tube protrudes beyond the jaws of the clamp, and advance it through the hole into the pleural space using your finger as a guide. Direct the tip of the tube posteriorly for fluid drainage or anteriorly and superiorly for pneumothorax evacuation. Advance it until the last side hole is 2.5 to 5 cm (1 to 2 inches) inside the chest wall. Attach the tube to the previously assembled suction-drainage system. The chest tube should be inserted with the proximal hole at least 2 cm beyond the rib margin. Position of the chest tube with all drainage holes in the pleural space should be assessed by palpation. Confirm the correct location of the chest tube by the visualization of condensation within the tube with respiration or by drained pleural fluid seen within the tube. Ask the patient to cough, and observe whether bubbles form at the water-seal level. If the tube has not been properly inserted in the pleural space, no fluid will drain, and the level in the water column will not vary with respiration.
  13. Suture the tube in place with 1-0 or 2-0 silk or other nonabsorbent sutures. The two sutures are tied so as to pull the soft tissues snugly around the tube and provide an airtight seal. Tie the first suture across the incision, and then wind both suture ends around the tube, starting at the bottom and working toward the top. Tie the ends of the suture very tightly around the tube, and cut the ends.
  14. Place a second suture in a horizontal mattress or purse-string stitch around the tube at the skin incision site. Pull the ends of this suture together, and tie a surgeon’s knot to close the skin around the tube. Wind the loose ends tightly around the tube, and finish the suture with a bow knot. The bow can be later undone and used to close the skin when the tube is removed. Alternatively, some choose to only use the purse-string to secure the chest tube. This usually involves wrapping the suture around the tube several more times than in the other method to ensure that the tube does not slip from location.
  15. Place petroleum gauze around the tube where it meets the skin. Make a straight cut into the center of two additional 4 X 4 inch sterile gauze pads, and place them around the tube from opposite directions. Tape the gauze and tube in place, and tape together the tubing connections. Obtain postero-anterior and lateral chest radiographs to check the position of the chest tube and the amount of residual air or fluid as soon as possible after the tube is inserted.
  16. Use serial chest auscultation, chest radiographs, volume of blood loss, and amount of air leakage to assess the functioning of the chest tube. If a chest tube becomes blocked, it usually may be replaced through the same incision. Chest tubes are generally removed when there has been air or fluid drainage of < 100 ml in 24 hours for more than 24 hours.