| 1. Inject local anesthesia (1–2% lidocaine) into the soft tissues |
| 2. A small incision is made in the skin to facilitate catheter entry |
| 3. An 18-guage trocar needle is introduced through the incision into the pleural space |
| 4. The inner stylet is removed and position is confirmed by aspiration of pleural fluid |
| 5. A 0.038-in stiff guidewire is advanced through the trocar into the pleural space and the trocar is removed |
| 6. Serial dilation is performed to the required catheter size |
| 7. The drain is advanced with a stiffener over the guidewire. As soon as the catheter enters the pleural space, the stiffener is disconnected and held in place as the catheter is advanced into the pleural space |
| 8. When the catheter is in satisfactory position, the stiffener and guidewire are removed leaving the catheter in place |
| 9. The pigtail is locked and secured externally with a suture |
| 10. Up to 1 L is aspirated to avoid reexpansion of pulmonary edema |
