Before beginning, it is essential to review the imaging to confirm the correct side and indication for the procedure. Additionally, the labs needed to be reviewed to ensure that there is no underlying coagulopathy that requires correction. This information is then used to obtain informed consent.
In this case, the patient was an 80-year-old female who was postoperative day five from a minimally invasive Ivor Lewis esophagectomy, presenting with a rising white blood cell count and a left-sided pleural effusion on chest X-ray. Before starting the procedure, supplies were collected. The necessary items included the pigtail catheter, two 0-silk sutures, sterilizing swabs, a laceration tray with a needle driver and scissors, a 22-gauge long seeker needle, a syringe, local anesthetic, a skin marker, a collection bottle for fluid to send to the microbiology lab, sterile towels, an analog or digital drainage device, sterile gloves and gown, and dressing supplies. An ultrasound machine may also be needed for draining liquid, as was the case here.
The patient was positioned sitting up in bed, leaning forward onto a table. The ultrasound was used to identify the best window to access the pleural effusion. A cardiac or phased array probe was used, as it balanced both resolution and depth. The depth is typically set to 16 centimeters in most situations, and the gain can be adjusted as desired. The probe could be oriented on either the long or short axis. The planned insertion site was marked. The skin was then sterilized in preparation for setting up the sterile supplies. Local anesthetic was infiltrated using the 22-gauge seeker needle to minimize the risk of injury. Following this, the seeker needle was slowly advanced perpendicular to the angle of the chest while aspirating and infiltrating the local anesthetic. This was done gradually until fluid was aspirated.
Once aspirated fluid was obtained, the needle was withdrawn slightly, and local anesthetic was infiltrated into the extrapleural plane as well as posteriorly into the intercostal space to create an intercostal block. Ideally, at least 20 ml of 1 percent lidocaine should be infiltrated at this time. The local anesthetic was then given time to work while the remainder of the sterile supplies were opened. It is recommended to set up all supplies in the order they will be needed. The authors’ pneumothorax kit included the pigtail catheter, stylet, dilator, short and long needle, scalpel, wire, extension tubing to connect to the drainage device, and a Heimlich valve.
The procedure then proceeded by advancing the needle from the kit at the anesthetized location. The key was to stay perpendicular to the angle of the chest while continuing to slowly advance and aspirate to avoid any injury to intrathoracic structures. As soon as fluid was aspirated, the syringe was disconnected. The wire was then advanced through the needle. An incision was made by sliding the blade over top of the wire, avoiding any skin bridges. The dilator was then slid over top of the wire positioned perpendicular to the angle of the chest, taking care not to kink the wire. Following this, the pigtail and the stylet were advanced over the top of the wire. Once the wire was seen at the other end of the pigtail, the pigtail was advanced into the chest.
As the pigtail was advanced, the wire and stylet were pulled back to minimize any intrathoracic injuries secondary to the stylet. As soon as the stylet and wire were removed, the stopcock was closed to prevent the entrainment of atmospheric air into the chest. The catheter was advanced as much as possible since it could be pulled back if too far in but cannot be pushed back in once inserted. The pigtail catheter was then secured using two 0-silk sutures.The extension tubing was used to connect the pigtail catheter to a drainage device. On the drainage device, drainage of pleural fluid, tidaling of the water column, and/or bubbling were observed, confirming that the pigtail catheter was inside the chest. A post-procedure chest X-ray was obtained to confirm the position of the pigtail catheter.
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References
- Gilbert S, French DG. Closed Pleural Drainage and Suction Systems. In: Meyerson S, Mokadam N, Jacobs JP, eds. Pearson’s General Thoracic Surgery. STS Cardiothoracic Surgery E-Book. Chicago: Society of Thoracic Surgeons; 2024. ebook.sts.org. Accessed March 19, 2026.
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