Review of chest tube drainage of the pleural space

This blog summarizes recommended management of chest tube drainage of the pleural space. The blog will cover the recommended size of chest tube for different indications, suggestions for chest tube insertion technique, methods to avoid chest tube complications and when to remove a chest tube:

1. Choice of chest tube size

• Small-bore chest tubes (14 F or smaller) are generally sufficient for spontaneous pneumothoraces, iatrogenic pneumothoraces and for pleural effusion drainage
• Large-bore chest tubes (20-28 F) are generally indicated for traumatic hemothoraces, management of large air leaks, malignant effusions that require a pleurodesis, tension pneumothorax, complicated empyemas or ineffective trial of small-bore chest tube drainage

2. Chest tube insertion

• Use bedside ultrasound to help guide insertion site above the diaphragm
• Position the patient semi-recumbent at 45 degrees with the ipsilateral arm over the head
• Introduce chest tubes immediately superior to rib
• Place the chest tube in the mid-axillary line above the diaphragm (usually in the 4^th intercostal space) and in the triangle of safety bordered superiorly by the axilla, medially by the lateral edge of the pectoralis major muscle and laterally by the medial edge of the latissimus dorsi.
• Avoid trocar chest tubes
• Introduce pigtail catheters using either the Seldinger technique or tube thoracostomy with blunt dissection
• Probe the intrapleural space using a finger to assure the pleural space has been entered
• Prophylactic cefazolin 2 gm IV x 1 is indicated for penetrating chest trauma or emergent tube thoracostomy performed without sterile technique
• Recommend procedural sedation for tube thoracostomy in non-sedated patients
• Small-bore chest tubes can be placed without blood products in emergent situations in patients with a platelet count above 20K, if the patient is on a thienopyridine (clopidogrel, ticagrelor or prasugrel) or if they are on therapeutic anticoagulation

3. Chest tube drainage systems

• Heimlich valves can be used for evacuation of a simple pneumothorax
• Three-compartment chest tube drainage systems can be used for pneumothoraces, pleural effusions or drainage of hemothoraces

4. To use wall suction or not?

• Wall suction should be used for evacuation of hemothoraces, pleural effusions and for treatment of a tension pneumothorax, incomplete lung re-inflation or persistent air leaks beyond 24 hours
• Can start with water seal for evacuation of a simple pneumothorax or initial drainage of massive pleural effusions (rapid drainage of chronic massive pleural effusions increase the risk of re-expansion pulmonary edema)

5. Chest tube removal

• Chest tubes should generally be removed within 2 weeks to avoid infectious complications
• Chest tubes placed for pneumothorax can be removed when the lung is fully re-inflated, there is no air leak and the patient has been stable on water seal for at least 6 hours
• In post-operative situations, there is no standardized chest tube output thresholds with safe removal with daily outputs as high as 450 mL. A more typical daily chest tube output threshold is 200 mL.
• Following pleurodesis, a daily output of 150 mL is a safe threshold for chest tube removal
• After a traumatic hemothorax or for pleural effusions unrelated to an elective surgery, a daily output threshold of 200 mL is safe.
• Remove the chest tube at full inspiration with the patient humming
• Cover the chest tube insertion site with a vaseline gauze pressure dressing for 48 hours

6. Minimizing chest tube complications

• Pre-procedural bedside ultrasound minimizes the incidence of diaphragmatic or abdominal organ injury
• Using a finger probe technique, minimizes the incidence of tube malposition in the chest wall tissue.
• Pleural space infections can be minimized by placing chest tubes using full sterile technique, using prophylactic cefazolin x 1 for penetrating chest trauma and removing chest tubes as soon the goal has been reached
• Bleeding complications can be minimized by inserting the chest tube directly above the rib and avoiding the infraclavicular space
• Minimizing re-expansion pulmonary edema (REPE) by using water seal initially for drainage of massive pleural effusions. Rapid drainage of chronic massive pleural effusions can cause REPE.
• Minimize intraparenchymal or great vessel injury by avoiding trocar chest tubes.

Reference:

Porcel, J. Chest Tube Drainage of the Pleural Space: A Concise Review for Pulmonologists. Tuberc Respir Dis. 2018; 81:106-115

Benns MV, et al. Does chest tube location matter? An analysis of chest tube position and the need for secondary interventions. J Trauma Acute Care Surg. 2015 Feb; 78(2):386-90

Taylor L.A. et al. Ultrasound-guided thoracostomy site identification in healthy volunteers. Critical Ultrasound J. 2018; 10: 28

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.