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  Do not confuse a pulmonary bleb or bullae for a pneumothorax.

  
  
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  The neurovascular bundle runs inferior to each rib. Always enter the thoracic cavity over the rib, never under.

  
  
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  Never advance or replace a tube that has migrated out of the chest. Always place a new one.

Needle thoracostomy is indicated for emergent decompression of suspected tension pneumothorax. Tube thoracotomy is indicated after needle thoracostomy, for simple pneumothorax, traumatic hemothorax, or large pleural effusions with evidence of respiratory compromise.

A pneumothorax on chest x-ray may be confused with a pulmonary bleb or bullae. Bullae and blebs are large gas-filled spaces with thin walls where pulmonary parenchyma has been destroyed, therefore greatly increasing alveolar size and mimicking pneumothorax. These are frequently located in the lung apices and are often seen in patients with severe chronic obstructive pulmonary disease. It is essential to confirm the presence of a pneumothorax before placement of a thoracostomy tube. See Chapter 24 for further clinical scenarios in which tube thoracostomy can be substituted for less invasive or conservative management of pneumothoraces.

Needle thoracostomy requires a 12- to 16-gauge angiocatheter, 3 to 4.5 inches in length, and a 5–10 mL syringe. Tube thoracostomy requires a 36- to 40-F tube for hemothorax in adults or 20- to 24-F tube in children. For a simple pneumothorax, an 18- to 28-F tube in adults or 14- to 16-F tube in children is sufficient. Additional supplies required for tube thoracostomy placement include povidone-iodine (Betadine) solution, sterile drapes, sterile gloves, 20 mL of 1% lidocaine with epinephrine, scalpel with #10 blade, large curved and straight clamps, a needle driver, 2-0 silk suture, and a commercial or 3-bottle suction apparatus.