Chest tube insertion – Pigtail

Pigtail Catheter Insertion Procedure

EMSJ Faculty Pearl

Dr. Paul Frankish & Dr. Matt Greer

Updated April, 2023

See Video of Pigtail Catheter Insertion Here

Equipment Update: 

Adults: Trauma carts should be stocked with 28Fr, 24Fr, 20Fr standard chest tubes and 14Fr pigtail catheter kits. It is recommended that we discontinue stocking larger sized chest tubes (32Fr, 36Fr) and Cook 9Fr pneumothorax set with metal trochar/needle.

Pediatrics: PALS carts should be stocked with 10Fr seldinger kits, 14Fr pigtail catheter kits and 20 Fr standard sized chest tubes.

  1. Obtain informed consent if possible, obtain all supplies needed, have drainage system opened and ready to go.
  2. Confirm 3-way stopcock attached to tube, then insert obturator through this 2. Sterile prep, drape, gown/glove.
  3. Identify triangle of safety (5th IC, mid axillary, pectoralis). – or use PoCUS to guide site safety and depth (DL)
  4. Anesthetize skin, subcutaneous, rib, intercostal, and pleura. Consider procedural sedation.

May need up to 20 cc of local, consider refreezing with larger spinal needle, withdraw until the air bubbles stop to freeze the pleura

5. Insert large “seeker” needle at desired IC space, with fluid filled syringe attached, withdraw as you go.

Note the depth when you get air bubbles for when you dilate the tract

6. Slide over superior aspect of rib and stop when you withdraw air bubbles/fluid.
7. Detach syringe and insert guidewire through needle. There should be no resistance. Only about 10 cm inside the thoracic cavity is required. Remove needle while leaving the guide-wire in place.
8. Make a small incision with 11-blade alongside guidewire, then dilate to required depth with dilator, then insert pigtail with obturator over wire to appropriate depth.

Remove the obturator once tube is within pleural cavity, then advance pigtail into chest

9. Insert as far as possible until resistance is felt to ensure all fenestrations are within the thoracic cavity.

You can always pull it back out if it’s in too far

10. Attach tubing extension, then to either Heimlich valve or underwater seal/wall suction.

Heimlich valve function is unidirectional. Attach blue end to chest tube

11. Suture in place as per usual chest tube technique. Ensure dressing optimizes skin seal (sticky/occlusive).
12. Confirm placement with chest x-ray.


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