New Guidelines for Chest Tube Removal

A collection of recent studies has helped determine the best protocol for removing chest tubes. For instance, a trial of water seal for at least six hours is recommended before discontinuation. The water seal reduces the need for another chest tube because it allows occult air leaks to become more obvious. Chest tubes should be removed when the lung is fully reinflated and there is less than 200-300 mL* non-infected fluid output in 24 hours.  Then, briskly remove the chest tube and cover wound immediately with xeroform gauze covered by sterile 4×4 pressure dressings. Also, there appears to be no difference in recurrent pneumothorax if the chest tube is discontinued at end-inspiration or end-expiration.

One study evaluated the outcomes of chest tube removal protocol using digital monitoring of air leak compared to a visual and subjective assessment of air leaks. Results showed that using the digital protocol significantly reduced hospital stay and average cost savings. Chest tube duration also declined as 51% of digital protocol patients had their chest tube removed on the second postoperative day compared to only 12% of traditional protocol patients.

Ultrasound to Guide Chest Tube Removal:

  • Linear array probe in longitudinal orientation
  • Scan midclavicular line in the first three interspaces
  • Water seal for at least 6 hours
  • Chest tube could safely be removed if lung sliding, comet tail artifacts in B mode and “seashore sign” in M mode seen at all 3 sites (designated by red circles in figure to the left)
  • Repeat bedside ultrasound 4-6 hours after CT discontinuation
  • 3.5% PTX recurrence rate

*The timing of chest tube removal based on 24 hour fluid output is not well studied and generally varies based on physician style. Many surgeons feel comfortable removing chest tubes once the daily output of non-infected fluid is <300 mL, but others prefer to wait until the output is <200 mL. One new study even suggests safe to remove when 24h output <400 mL


Martino K, et al. Prospective randomized trial of thoracostomy removal algorithms. J of Trauma, Injury, Infection and Critical Care. 1999; 46: 369-373.

Zardo P, et al. Chest tube management: state of the art. Curr Opin Anaesthesiol. 2015 Feb;28(1):45-9.

Brunelli A, et al. Evaluation of a new chest tube removal protocol using digital air leak monitoring after lobectomy: a prospective randomized trial. Eur J Cardiothorac Surg. 2010 Jan;37(1):56-60.

Jensen K, et al. Early chest tube removal after video-assisted thoracic surgery lobectomy with serous fluid production up to 500ml/day. Eur J Cardiothorac Surg. 2014 Feb;45(2):241-6.

Lavingia KS, et al. Basic ultrasound training can replace chest radiography for safe tube thoracostomy removal. Am Surg. 2014 Aug; 80 (8):783-6.

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