Important Updates in Chest Tube Management: Part 2

chest tube management The insertion of chest tubes or tube thoracostomy is an effective way to drain blood, air, pus, and other fluids from the thorax to address pleural effusion. It is part of postoperative care for cardiothoracic surgeries which involve the lungs, heart, and esophagus.

Despite associated complications and risks, tube thoracostomy remains a life-saving emergency procedure that’s essential for recovery in a number of situations.

In the first part of this series, we covered what chest tube drainage is, how it works, and its indications and contraindications. In this second part, we dive deeper into the subject by examining the different types of chest tubes, how to manage them for the best outcomes, and when to stop using them.

Types of Chest Tubes

Chest tubes are available in several sizes. They are classified according to their internal diameters. A French catheter scale is used for classification, with abbreviations of Fr or simply F. A single Fr is a third of a millimeter. Common sizes range from 6 Fr to 40 Fr.

With structures similar to plastic straws, they have three main parts:

  • The chest tube has markings to indicate how far the tube has been inserted.
  • The tip features drainage holes to remove air and fluids.
  • The end or tail is slightly tapered, enabling easy connection to a suction or chest tube drainage system. 

Some chest tubes have coils toward the ends. These are known as pigtail catheters. 

Chest tubes are divided into large-bore and small-bore varieties:

  • Chest tubes 20 Fr and larger are characterized as large-bore chest tubes.
  • Chest tubes smaller than 20 Fr are small-bore chest tubes.
  • Tunneled pleural catheters are smaller tubes that can be placed in the chest for long-term use among patients with chronic infections, liver disease, cancer, and recurrent pleural effusions.

The size and type of the chest tube used depends on the procedure and the patient’s anatomy.

Which Chest Tubes Are More Effective for Traumatic Hemothorax Treatment?

Hemothorax is when blood accumulates in the pleural space. Traumatic hemothorax is caused by blunt, or penetrating injuries to the thoracic area. Traumatic injuries to the chest are among the primary causes of hemothorax. 

But which is more effective for treating hemothorax and hemopneumothorax—pigtail catheters or large-bore chest tubes

A randomized clinical trial concluded that chest tubes from 32 Fr to 40 Fr are as effective as 14 Fr pigtail catheters in terms of drainage. However, for traumatic hemothorax, researchers found that 14 Fr pigtail catheters were better for chest drainage than 28 Fr to 32 Fr chest tubes.

The overall results showed that pigtail catheters may be an effective alternative to chest tubes. Additionally, they can also aid in chest tube pain management since they are less painful than large-bore tubes.

Effective Chest Tube Management and Enhancing Outcomes

Typically, the first step for effective chest drain management involves monitoring the drain and recording outcomes. This allows clinicians to make informed adjustments.

For efficient monitoring, the patient must be observed every hour for the first 4 hours after the chest drain insertion. They can then be monitored every 4 hours to ensure that the fluid within the tube swings or oscillates with respiration according to changes in the intrapleural pressure.

Regular examination is also essential in evaluating all other aspects of the drainage system and the patient. These checks entail inspecting the:

  • Clamping of the chest drain
  • Suction of the drainage
  • Skin integrity
  • Drain bottle and dressing, changing them if necessary
  • Mobility of the patient
  • Anchoring of the drainage
  • Area of insertion for signs of infection
  • Water chamber for air leaks
  • Drainage volume
  • Color and consistency of the drainage
  • Swing or oscillation of the water column in the water seal compartment to assure line/tubing patency 

With consistent and regular observation, any changes in the overall drainage can be recorded for reference. This helps improve the accuracy of medical care. It also ensures that any issues concerning the drainage system and patient are diagnosed and addressed promptly.

Overall, this aids in enhancing patient outcomes while ensuring that conditions such as pneumothorax can be alleviated with chest tube drainage. While some patients may still require surgery, proper chest tube management ensures the optimization of chest tube drainage.

When To Stop Using Chest Tubes

Chest tubes may also be used to administer sclerosing agents, antibiotics, fibrinolytics, and saline after the fluid is removed. This is a procedure called pleurodesis that can be used for recurrent pleural effusions as occurs in a malignant pleural effusion

While leaving a chest tube inside the pleural space can cause complications, such as infections and longer hospital admissions, taking them out too early can also be counterproductive. 

It is, therefore, crucial to know when you should remove chest tubes:

  • After thoracic surgery, chest tubes may be removed when there is no air leak and the lung remains inflated for at least 6 hours while on water seal (without the use of suction) and the 24 hour fluid output is less than 200 mL.
  • After drainage of a pleural effusion or hemothorax, the removal of chest tubes is less standardized. It typically varies depending on the institution but most studies show that chest tubes can be safely discontinued when the patient is clinically stable and the 24 hour output is less than 200 mL.

Once the chest tubes can be removed, practitioners can consider the different methods of chest tube removal such as water suction and water seal. 

Final Thoughts

Effective chest tube management is crucial for enhancing patient outcomes and ensuring successful chest tube drainage. Proper observation and knowing when to remove chest tubes are just some of the considerations that must be learned.

We hope that this series has given you a sufficient background on effective chest tube management. To receive training on these matters, look into Hospital Procedures Consultants’ Tube Thoracostomy: Chest Tube Course. It will provide you with a deeper appreciation for chest tube insertion, maintenance, removal techniques, and more.


Lobdell, K. Engelman, D. Chest Tube Management: Past, Present, and Future Directions for Developing Evidence-Based Best Practices. Innovations. 2023 18(1):41-48.
Roebker, J. Kord, A. Chan, K. Rao, R. E Ray, C. Ristagno, R. Chest Tube Placement and Management: A Practical Review. Semin Intervent Radiol. 2023 Jun 16;40(2):231-239.
Haider, S. Taha Kamal, M. Shoaib, N. Zahid, M. Thoracostomy tube withdrawal during latter phases of expiration or inspiration: a systematic review and meta-analysis. Eur J Trauma Emerg Surg. 2023 Jun 22. doi: 10.1007

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Tags: chest tube, chest tube management, chest tube pain management

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