Iowa Neonatology Fellows
Peer Review Status: Internally Peer Reviewed

Pulmonary air leak is an anticipated risk of mechanical ventilation. Drainage of air or fluid accumulation in the thorax is an important and necessary skill and is often performed emergently.


  • Evacuation of pneumothorax
  • Evacuation of large pleural fluid collections
    • chylothorax
    • empyema
    • hemothorax 
  • A small spontaneous pneumothorax in the absence of lung disease will most likely resolve without intervention. 

When evaluating a suspected pneumothorax, auscultation and transillumination of the chest should be performed. Note that false positives may result from subcutaneous edema or air. If positive, consider needle aspiration performed with a 20 or 22 gauge needle connected to a 30 cc syringe via a 3-way stopcock. After prepping with alcohol, insert needle 3-5 mm into the chest wall in the fourth or fifth intercostal space in the anterior axillary line. If the infant is supine, air may be easier to access via the second intercostal space in the mid-clavicular line. 

If pneumothorax is under tension or reaccumulates following needle aspiration, the insertion of a chest tube (CT) will be necessary. Appropriate insertion sites include the fourth, fifth or sixth intercostal spaces in the anterior axillary line. The nipple is a landmark for the fourth intercostal space.

Insertion (see figure below) 

  • A 8, 10 or 12 French CT used depending on the size of the infant.
  • Position infant supine or with the affected side elevated 45-60 degrees off the bed using a towel or blanket as back support. This has an advantage of allowing air to rise to the point of entry and of encouraging the correct anterior direction of the CT.
  • The skin is prepped with alcohol and sterilely draped.
  • A 1 cm incision is made through the skin on top of the rib to facilitate entry of the CT. Using a small curved forceps, separate the tissue down to the pleura.
  • Grasping the end of the CT with the tips of curved forceps, apply pressure until the pleural space is entered. Do not use the trocar. Direct CT toward apex of thorax (midclavicle) and advance CT assuring that side holes are within thorax. Observe for cloudiness, vapor or bubbling in CT to verify intrapleural location. 
  • The chest tube should be inserted 2-3 cm for a small preterm infant and 3-4 cm for a term infant. (These are approximate guidelines only.) 

After CT insertion connect the tube's distal end to a water seal system such as a PleurevacR. To apply suction, use 15-20 cm of water in the PleurevacR column. If multiple CTs are placed, each CT should be connected to it's own water seal system and suction source. 

Secure CT to skin with suture and cover incision site with vaseline gauze and/or TegadermR dressing. 

After thoracentesis or CT insertion a chest x-ray, A/P and lateral should be obtained. 

If there is a persistent pneumothorax despite a properly placed CT, consider increasing the column of water by 5 cm increments up to 30 cm before inserting a second CT. 

Prior to removal, the CT should be clamped for 2-4 hours or longer. If there is no reaccumulation of air, the CT can be removed. 


  • Misdiagnosis with inappropriate CT placement
  • Malpositioned CT
  • Trauma
    • lung laceration or perforation
    • laceration and hemorrhage of major vessel (axillary, intercostal, pulmonary, internal mammary)
    • puncture of viscus with path of tube
  • Infection 

Chest tube insertion


Mehrabani D, Kopelman AE: Chest tube insertion: A simplified technique. Pediatr 1989;83:784-785.