Chest Tube Placement (Tube Thoracostomy)
[Right / Left] chest tube placement (tube thoracostomy)
[Right / Left] [pneumothorax / hemothorax / hemopneumothorax / pleural effusion / empyema] requiring tube thoracostomy for [lung re-expansion / drainage].
[Informed consent was obtained from the [patient / patient's surrogate] after discussion of risks, benefits, and alternatives / The procedure was emergent, and consent was implied].
[***, MD/DO]
Local: [X] mL 1% lidocaine without epinephrine, [IV analgesia / anxiolysis as needed]
The [right / left] pleural space was entered in the [4th / 5th] intercostal space at the mid-axillary line. [A rush of air / Frank blood / Turbid fluid / Purulent material] was encountered. The lung was [palpable / not palpable] through the tract. [X] mL of [sanguineous / serosanguineous / turbid] fluid drained immediately. Post-procedure chest radiograph showed [appropriate tube position / lung re-expansion / no residual pneumothorax / reduction in hemothorax].
A time-out was completed confirming the patient, procedure, and side. The patient was positioned supine with the ipsilateral arm raised and abducted, with the hand behind the head to open the axillary space. The [right / left] lateral chest wall was prepped with chlorhexidine and draped in sterile fashion. Sterile gown and gloves were worn.
The [4th / 5th] intercostal space at the mid-axillary line was identified by palpation of the rib margins. The skin, subcutaneous tissue, intercostal muscles, and parietal pleura were infiltrated with [X] mL of 1% lidocaine, anesthetizing the superior surface of the lower rib to avoid the intercostal neurovascular bundle.
A [2–3 cm] transverse skin incision was made over the [5th / 6th] rib. Blunt dissection with a curved Kelly clamp was carried through the subcutaneous tissue and intercostal muscle along the superior surface of the rib, entering the pleural space with a controlled pop. The tract was widened with the clamp, and a gloved finger was inserted to confirm pleural entry, sweep for adhesions, and palpate the lung.
A [X] Fr chest tube was grasped with the clamp and directed [anterosuperiorly for pneumothorax / posteroinferiorly for effusion or hemothorax]. The tube was advanced to the [3rd / 4th] mark at the skin, and all side holes were confirmed within the pleural space. Immediate drainage of [air / blood / fluid] was noted. The tube was connected to a water-seal drainage system [with -20 cmH2O suction].
The tube was secured to the skin with a [0-silk] suture, and an occlusive petroleum gauze dressing was applied.
[X] Fr chest tube, [right / left] pleural space, secured at the [X] cm mark, to water seal with [-20 cmH2O suction / gravity drainage]
Minimal
[Pleural fluid sent for cell count, LDH, protein, culture, and cytology as indicated / None]
None
The patient tolerated the procedure well and is being monitored in the [ICU / step-down unit / floor] in stable condition. Chest tube output and air leak will be monitored [with daily chest radiographs].
Epic SmartPhrase Version
PROCEDURE: [Right / Left] chest tube placement (tube thoracostomy)
INDICATION: [Right / Left] *** requiring tube thoracostomy.
CONSENT: [Informed consent obtained from the [patient / surrogate] after discussion of risks, benefits, and alternatives / Emergent, consent implied].
PERFORMED BY: ***, MD/DO
ANESTHESIA: Local: *** mL 1% lidocaine without epinephrine
FINDINGS: *** ICS entered at mid-axillary line. *** encountered on finger sweep. *** mL *** fluid drained immediately. Post-procedure CXR: ***.
PROCEDURE DETAILS:
Time-out completed. Patient positioned supine with ipsilateral arm raised. *** chest wall prepped and draped in sterile fashion.
*** ICS at mid-axillary line identified. Skin, subcutaneous tissue, and pleura infiltrated with *** mL 1% lidocaine along superior rib margin. *** cm incision made over lower rib. Blunt Kelly dissection through intercostal muscle into pleural space. Finger sweep performed. Pleural entry confirmed, no adhesions in tract. *** Fr chest tube directed *** to *** mark at skin, all side holes within pleural cavity. Connected to water-seal with *** suction. Secured with *** suture, petroleum gauze dressing applied.
DEVICE PLACED: *** Fr chest tube, *** pleural space, secured at *** cm, to water seal with *** suction
EBL: Minimal
SPECIMENS: ***
COMPLICATIONS: None
POST-PROCEDURE PLAN: Tolerated well, monitored in stable condition. Chest tube output and air leak to be monitored.
Signed: .ME, .MYDEGREE
.TODAYVariants
Tension Pneumothorax: Needle Decompression First
Given hemodynamic instability and clinical signs of tension pneumothorax (tracheal deviation, absent breath sounds, hypotension, distended neck veins), immediate needle decompression was performed prior to formal tube thoracostomy. A 14-gauge angiocatheter was inserted into the [2nd intercostal space at the mid-clavicular line / 4th–5th intercostal space at the anterior axillary line]. [The AAL site is preferred in patients with large body habitus, as the chest wall is thinner at this location and decompression success rates are higher (per EAST guidelines and ATLS 10th ed).] A rush of air was confirmed. The patient's hemodynamics improved immediately. Formal tube thoracostomy was subsequently performed as described above.
Hemothorax
A [X] Fr chest tube was placed posteroinferiorly for drainage of hemothorax. [X] mL of frank blood drained immediately. The tube was connected to an autotransfusion system [or standard water-seal].
Empyema / Complicated Parapneumonic Effusion
Thick, turbid, [foul-smelling] fluid consistent with empyema was encountered on pleural entry. A [X] Fr tube was directed posteroinferiorly. The fluid was sent for Gram stain, culture, cell count, pH, LDH, protein, and glucose. Fibrinolytic therapy (tPA/DNase) was discussed with the primary team for loculated empyema. [Thoracic surgery was consulted for consideration of VATS decortication if tube drainage fails.]
Charting Tips
- Document finger sweep explicitly. Confirm pleural entry, absence of adhesions, and that all tube side holes are within the pleural cavity. This is the key step that distinguishes a properly placed tube from a malpositioned one.
- Always document immediate output (volume and character) and post-procedure CXR findings specifically. For hemothorax, record initial output and hourly output, since more than 1500 mL immediately or more than 200 mL/h for 2 to 4 hours prompts consideration of operative exploration.
- Document neurovascular bundle avoidance by noting 'dissection along the superior border of the lower rib.' This establishes that proper technique was used if intercostal vessel injury is later alleged.
Documentation & Reimbursement Considerations
- Primary service: Report Chest Tube Placement (Tube Thoracostomy) as the primary service when it is the definitive operation performed.
- Tube thoracostomy (2.96 wRVU, 0-day global) covers standard chest tube placement for pneumothorax, hemothorax, pleural effusion, or empyema.
- Image-guided pleural catheter placement (3.04 wRVU, 0-day global) is reported when ultrasound or CT guidance is used to place a pigtail or small-bore catheter. It replaces tube thoracostomy, so do not bill both.
- 0-day global: no bundled postoperative period. Daily chest tube management (flushes, repositioning checks) does not generate separate procedure charges.
- If a thoracentesis is performed first and then a chest tube is placed in the same session, only the chest tube code is billed. The diagnostic aspiration is bundled.
- The image-guided service requires documentation of real-time imaging, a permanent record, and a separate imaging report or integrated procedure note confirming guidance. Without this documentation, standard tube thoracostomy is the appropriate code.