Pearls about Chest Tube Management

Chest tubes, or thoracostomy tubes, have been used since the fifth century BC when Hippocrates described the use of a hollow tin tube to drain fluid that was likely an empyema from his description.[i] Chest tubes started to be used in 1922 to aid in the postoperative care of patients undergoing thoracic surgery.[ii] Chest tubes are now used routinely for the management of spontaneous, traumatic or iatrogenic pneumothoraces, complicated or infected parapneumonic effusions and for postoperative care in patients who have undergone thoracic or cardiac surgeries. Despite the wide use of chest tubes for centuries, the evidence to inform our decisions about chest tube management is largely based on low-quality evidence and expert opinion. In this blog, I will try to summarize some specific recommendations based on the studies we do have:

Management of complicated parapneumonic effusion (PPE) or infected PPE/empyemas

  • Thoracentesis is usually performed to make the diagnosis of an empyema or complicated PPE. A complicated PPE is defined as a pleural effusion with a pleural fluid pH <7.20 or pleural fluid glucose <40-60 mg/dL with clinical signs of infection or a positive pleural fluid culture. The pleural fluid LDH is usually >1,000 IU/L and pleural fluid WBC is usually >10,000[iii]
  • Place small-bore chest tube (<20 F) within 24 hours for simple empyemas[iv] and administer TPA 10 mg and 5 mg DNase concurrently twice a day with a 2 hour dwell time for 3 days. The tube should also be flushed with 15 mL sterile saline three times daily[v], [vi]
  • Large bore chest tubes (>20 F) are usually needed for more viscous empyemas and multi-loculated empyemasiv
  • Recommend consulting thoracic surgery after 72 hours of treatment for ongoing pleural sepsis or unsatisfactory radiographic improvement despite intrapleural lytics[vii]

Management of retained traumatic hemothorax

  • Place large-bore chest tube (>20 F) as drainage of hemothorax often inadequate with small-bore chest tubes
  • Treatment with tube thoracostomy drainage and intrapleural TPA decreased the need for VATS operation by about 87% over controls[viii]

Management of Pneumothorax

  • Place a small-bore chest tube such as a £14 F Pigtail catheter or needle aspiration is recommended for spontaneous pneumothorax that are associated with at least 15% lung collapse[ix]
    • There are studies that suggest that observation is non-inferior to chest tube management for a large spontaneous pneumothorax up to 30% lung collapse that is not associated with significant chest pain, dyspnea, need for supplemental oxygen, the patient can ambulate comfortably and is unchanged on repeat chest x-ray after 4 hours.
  • Can switch from wall suction to water seal once the lung is fully reinflated
  • Give prophylactic cefazolin 2 gm IV x 1 for any chest tube placed for a traumatic pneumothorax or hemothorax unless the chest tube is placed under completely sterile conditions. This practice led to a 6.3% ARR of empyema and pneumonia over controls (NNT = 16).[x]

Management of a Persistent Air Leak

  • Trial of water seal often resolves an air leak faster than wall suction
  • Consult a thoracic surgeon after 3-5 days of a persistent air leak for possible VATS

Chest Tube Removal

  • May remove the chest tube at either end-inspiration while the patient is humming or end-expiration while the patient performs a Valsalva maneuver.[xi]
  • May remove chest tubes placed for a pneumothorax if the lung remains fully inflated on water seal for at least 4-6 hours
  • May remove chest tubes placed for effusions if the fluid is without blood, chyle and is non-purulent and the 24 h output is less than 200 mL
    • This is one of the most controversial areas of chest tube management and there is little consensus about this. Some pulmonary specialists will remove chest tubes when the 24 h output is as high as 450 mL, but most experts concur that a threshold of 200 mL is a safe chest tube output for chest tube removal.


[i] Hippocrates. The Genuine Works of Hippocrates. Adams F. trans-ed. Sydenham Society: 1849

[ii] Lillenthal H. Resection of the lung for suppurative infections with a report based on 31 operative cases in which resection was done or intended. Ann Surg. 1922: 75 (3): 257-320.

[iii] Ferreiro L et al. Management of Pleural Infection. Expert Review of Respiratory Medicine. 2018; 12(6): 521-535

[iv] Cooke DT et al. Large-bore and Small-bore Chest Tubes: types, function and placement. Surg Clin.2013; 23(1): 17-24.

[v] Redden MD et al. Surgical vs Non-surgical Management of Pleural Empyema. Cochrane Database Syst Rev. 2017; 3(3): CD010651.

[vi] Rahman NM, Maskell NA, West A, et al. Intrapleural use of tissue plasminogen activator and DNase in pleural infection. N Engl J Med 2011;365(06):518–526

[vii] Anderson D et al. Comprehensive Review of Chest Tube Management: A Review. JAMA. 2022; 157(3): 269-274.

[viii] Hendricksen BS et al. Lytic therapy for retained traumatic hemothorax: a systematic review and meta-analysis. Chest. 2019; 155(4): 805-815.

[ix] Aragaki-Nakahod A. Management of Pneumothorax: an update. Curr Opin Pulm Med. 2022; 28: 62-67

[x] Ayoub F et al. Use of prophylactic antibiotic in preventing complications for blunt and penetrating chest trauma requiring chest drain insertion: a systematic review and meta-analysis. Trauma Surg Acute Care Open. 2019; 4: e000246

[xi] French DG et al. Optimizing postoperative care protocols in thoracic surgery: best evidence and new technology. J Thorac Dis. 2016;8(suppl 1):S3-S11.

Read all articles in blunt trauma, Chest Pain, Chest tube, chest tube placement, chest tube position, Chest tube removal, chest tube size, chest tubes, emergency procedures, empyema, Featured, hospital procedures, HPC Updates, parapneumonic effusion, pleural effusions, pleural fluid analysis, pneumonia, Pneumothorax, POCUS, Prophylaxis, Small-bore chest tube, Thoracentesis, thrombolysis, Tube Thoracostomy, Ultrasound-Guided Thoracentesis
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