1. Restrain the patient in the supine position and extend the arm to 90° on the affected side. Monitor heart rate, respiratory rate, and oxygen saturation if possible.

2. Mark the site for placement of the tube. Placement of the tube is at the second or third intercostal space on the midclavicular line. Posterior placement of the chest tube is at the fifth or sixth intercostal space on the anterior axillary line.

3. Clean the area with iodine solution. Infiltrate the site of insertion with lidocaine, and then infiltrate the intercostal muscles and parietal pleura. Incise the skin over the rib, 1 to 1.5 cm.

4. Take the curved hemostat, and, with the tip in the incision, enter the chest cavity just above the rib. Avoid the intercostal nerve, artery, and vein, which run on the lower edge of the rib.

5. Spread the hemostat open and slide the chest tube between the blades of the hemostat to the point where the side holes on the tube are within the pleural cavity. Connect the tube to a water-sealed vacuum system and apply 5 to 10 cm of negative pressure.

6. Increase the pressure to reduce the pneumothorax, if necessary.

7. Close the skin wound and secure the chest tube with silk suture. Verify the position of the chest tube with a chest x-ray. The lung should reexpand promptly following evacuation of the air in the pleural space.

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