Equipment Povidone-iodine or chlorhexidine antiseptic solution Sterile gown, mask, hat, gloves, gauze, and drapes No 11 blade scalpel; 5- to 10-mL syringe; needle (18- to 25-gauge) for anesthetic; 1% lidocaine Needle driver; scissors; strong, nonabsorbable suture Over-the-wire catheter (“pigtail”) kit, including catheter, dilator(s), introducer needle with wire, and tubing adaptor Pleural drainage system (e.g., Pleur-evac) Procedure Thoracostomy (“pigtail”) catheters can be used to evacuate air or pleural fluid from the pleural space They are not useful for evacuating empyema or blood because of the smaller diameter compared to that of a traditional thoracostomy tube Identify the side(s) with the pneumothorax/effusion by physical examination and chest radiograph Ultrasound may be helpful in guiding needle placement for pleural effusion Consider pharmacologic sedation if patient condition allows If abdominal distension is present, especially from a dilated stomach, pass a largebore nasogastric tube to decompress the stomach and reduce diaphragmatic elevation Restrain the child, if necessary Generally, a young or seriously ill child should be supine, but an older, cooperative patient may sit Locate the landmarks and cleanse the site with antiseptic solution Using aseptic technique with sterile gown, gloves, and mask, create a sterile field Infiltrate the skin, subcutaneous tissue, intercostal muscles, and periosteum of the rib with local anesthetic (1% lidocaine) The appropriate sites are the same as described in section Insertion of a Chest Tube for larger-bore thoracostomy tubes Introduce the needle over the rib to avoid the neurovascular bundle Aspirate as the needle is advanced into the pleural space For pneumothorax, sterile saline may be added to the aspirating syringe to identify air bubbles when the parietal pleura is penetrated Firmly grasp the needle as the syringe is removed Insert the wire through needle and into the pleural space The wire should pass easily into the pleural space The proceduralist must maintain a hold on the wire, and the wire only needs to be advanced far enough into the pleural space to avoid falling out with minor manipulations Remove the needle while carefully maintaining the position of the wire Using the scalpel, make a small incision at the skin entry point prior to dilation of the subcutaneous tissues Insert the dilator into chest wall (insert to a depth slightly beyond the anticipated thickness of the chest wall, but there is no need to automatically insert to the hub of the dilator) Remove the