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To evaluate pain associated with chest tube insertion in a group of patients with malignant pleural effusions.Prospective case series.Acute care cancer center in an academic institution.Fifty-two patients with symptomatic malignant pleural effusions. Twenty-six evaluated by conventional approach to chest tube insertion (group 1), 26 evaluated after institution of a new chest tube protocol (group 2).A new protocol was designed to improve pain control during chest tube insertion. The protocol included improved housestaff and nursing education, premedication, proper insertion techniques, and more liberal and precise delivery of local anesthetic.Both groups were evaluated by a verbal self-report scale (1-10) to assess pain and anxiety.The mean pain rating in group 1 was 6.2 (±0.76) compared with 3.7 (±5.6) in group 2 (p < 0.01). In group 1, pain or anxiety was 9 or 10 in 12 of 26 on a scale of 1 to 10, compared with 2 of 26 in group 2 (p < 0.001). Anxiety rating was 4.5 (±0.72) in group 1 compared with 1.5 (±0.54) in group 2 (p < 0.01).Chest tube insertion was associated with an unacceptably high level of pain and anxiety in our hospital. A new protocol, including housestaff education and changes in nursing policies, technical aspects, local anesthetic dose and delivery, and premedication, allowed us to approach the goal of a painless chest tube insertion.