Placement of a chest tube outside of the thoracic cavity or a diaphragmatic injury will result in an iatrogenic pneumothorax, an unresolved pneumothorax, or a tension pneumothorax.^6,7 Placement of the chest tube through or below the diaphragm will cause the tube to become lodged in the abdominal cavity, and the pulmonary pathology initially requiring the tube will persist. The consequences, repair, and prevention of intraabdominal placement of a tube are discussed later.

Insertion should be in the safe triangle bordered by the anterior border of the latissimus dorsi, the lateral border of the pectoralis major muscle, a line superior to the horizontal level of the nipple, and an apex below the axilla.⁵ During full expiration, the diaphragm rises to the fifth rib/fourth intercostal space (Fig. 11-1). Identifying a site in the fourth intercostal space midaxillary line helps to avoid diaphragmatic and abdominal cavity penetration. The highest rib space in the axilla adjacent to the nipple is usually the fourth or fifth, or alternatively, the rib spaces may be counted down from the second rib at the sternomanubrial joint (Fig. 11-2; see also Fig. 11-1).⁸

Infection of the wound site results in cellulitis, leukocytosis, and an increased risk of developing an empyema or necrotizing soft tissue infection. Necrotizing soft tissue infection typically presents with wound pain; crepitus; foul, watery wound discharge; skin blistering; and rapid progression to septic shock 3 to 5 days after insertion of a chest tube.⁹ A chest tube placed for an empyema is associated with an increased risk of developing a necrotizing chest wall infection.

A large area of skin cleansing using iodine or chlorhexidine should be undertaken.⁵ Prophylactic antibiotics do not reduce the incidence of wound infections in routine chest tube placement and are, therefore, not indicated.^10,11 However, they may be considered in the setting of penetrating trauma. The wound site should be examined daily.

An empyema may cause respiratory compromise/failure. The incidence of this complication reported in the literature varies widely from 1% to 25%.¹² The true source and route of infection may be difficult to determine; however, the rate of empyema is higher when a pleural effusion is present prior to tube insertion.¹²

Although tube thoracostomy may lead to infectious complications by providing an entrance for contamination, the true route and source of infection for development of an empyema are difficult to determine.¹² The best way to prevent empyema is by use of the aseptic technique. Prophylactic antibiotics have not been shown to reduce the incidence and, therefore, are not recommended for routine use of chest tube placement.^10,11,13

Damage to an intercostal vessel may cause an iatrogenic hemothorax. In rare instances, it may result in an arteriovenous fistula either between an intercostal artery and a subcutaneous vein or from an internal thoracic artery draining into a lobar pulmonary artery.¹⁵ The clinical manifestations of a fistula may be immediate or delayed.