DECIDEUse a pigtail, first-line for pneumothorax — spontaneous, iatrogenic or traumatic. · Use a pigtail for effusion and empyema — small-bore is commonly used for these. · Traumatic hemothorax needs a chest tube, not a pigtail — 28–32 Fr — see Chest Tube. · Large bore, not a pigtail: hemothorax, instability, theatre drainage, big air leak. · Relative contraindications: coagulopathy, overlying infection, adhesions or loculation.
STEPS · ◆ KEY STEP — LOGGED WITH ITS TIME
SIZE AND SITE
This site stocks one size: 14 Fr.
Triangle of safety. Insert at the 4th–5th space, mid- to anterior-axillary line.
Never below the nipple line.
Always over the UPPER border of the rib below.
Aim the catheter anterior and superior for air, posterior and inferior for fluid.
An anterior 2nd-space midclavicular pigtail is deliberately not described here.
ULTRASOUND
Scan at the bedside immediately before, in the position they will be in.
Confirm the fluid, the depth to pleura, and where the diaphragm and organs are.
Re-scan afterwards for sliding or for clearance of the fluid.
THE SELDINGER SEQUENCE
1. Consent, timeout, monitoring, analgesia. Head up 30–60°, arm behind the head.
3. Lidocaine 1% — up to 3.0 mg/kg, never more than 250 mg (≈20 mL in an adult).
4. Introducer needle over the upper border of the rib, aspirating continuously. Air or fluid confirms entry.
5. Wire in 15–20 cm, or just past the needle. It must always slide freely, and never come back.
6. Number 11 blade, a skin nick of about 1 cm beside the wire.
7. Dilate sequentially with gentle twisting. Re-check free wire movement after EACH dilator.
8. Catheter and stiffener over the wire to 15–20 cm. Last side hole inside the pleura.◆ PIGTAIL IN THE PLEURA
9. Confirm: aspirate air or fluid, look for respiratory swing and fogging, re-scan.
10. Suture with 0 or 1-0 silk or nylon, occlusive dressing, loop the tubing, underwater seal with the bottle ~100 cm BELOW the chest. CXR for every patient.
DRAINAGE, COMPLICATIONS, PITFALLS
Underwater seal first. Suction only if the pneumothorax persists or the effusion is large — −20 cmH₂O. Swing means patent; bubbling on coughing means an air leak.
Never clamp a bubbling drain.
Re-expansion pulmonary edema: drain a maximum of 1.5 L, then clamp briefly.
Guidewire loss into the pleural space.
Malposition, intercostal artery injury, organ laceration, blockage, dislodgement, infection.