Thoracostomy or the insertion of chest tubes (CTs) is a frequent procedure in clinical practices. After inserting chest tubes in the patient’s pleural cavity, they become a route for administering antibiotics, sclerosing agents, fibrinolytics, and saline.
Meanwhile, indwelling pleural catheters (IPC) are often first-line palliative treatments for persistent benign and symptomatic malignant pleural effusions.
The time CTs are left inside the pleural space can significantly lengthen a patient’s hospital stay and cause local infections but taking them out too early can result in unnecessary complications. In this article, we discuss when practitioners should remove chest tubes, removal techniques, the methods used to determine timing, and more.
Conditions for Chest Tube Removal
Most CTs can be left inside a patient’s pleural cavity for over two weeks. However, the longer they remain inserted, the higher the risk of complications. On the other hand, aspiration drain systems or pleural taps made from polyurethane must be extracted within three days or less after being installed.
Removing Chest Tubes After Thoracic Surgery
The appropriate time to remove CTs is when their therapeutic objectives have been reached or when they stop functioning. In cases where the patient undergoes CT placement for pneumothorax (PTX), CTs can be removed without a chest radiograph or clamp trial as long as a digital drainage monitoring device indicates the absence of air leaks and the lung remains inflated (resolved pneumothorax) while on water seal for at least 6 hours.
Chest tubes can be removed once air flow remains below 20 milliliters per minute for eight to 12 hours or lower than 40 milliliters per minute for six hours when no suction is used.
If drainage analog devices are used, the clinician can check for full expansion of the lung through a chest x-ray without suction and the absence of air bubbles in the water seal chamber. If bubbles in the chest tube are noted, it must never be clamped due to the risk of tension pneumothorax.
In some cases where the attending physician wants to ensure the absence of air leaks, they may opt to do a clamp trial for a few hours to see if its removal can be tolerated by the patient. This is, however, a risky strategy that entails close monitoring of the patient and delays CT removal.
Removing Chest Tubes After Pleural Effusion
Removing chest tubes after pleural effusion is less standardized. It varies according to the underlying condition being treated. Following surgery, CTs can be safely extracted once daily outputs reach up to 450 milliliters. However, the daily chest tube output at which CTs are removed is very operator dependent and not standardized. Most pulmonary specialists agree that a 200 mL daily output is a safe output at which CTs can be safely discontinued. After pleurodesis, some clinicians take CTs out when fluids go below 100 to 150 milliliters per day. Others perform removal once a specific time has elapsed after the sclerosing agent has been administered and irrespective of the amount of fluid output.
Before removing the chest tube, the suction should be removed, a water seal is applied, and be quickly taken out towards the end of the expiration of a Valsalva maneuver. After a sterile dressing is placed on the site of insertion, the wound is sutured and an occlusive dressing with iodopovidone is used to cover the opening.
When the fluid drained from IPC patients goes below 50 milliliters three consecutive times, clinicians assume the occurrence of spontaneous pleurodesis after ruling out the possibility of pleural fluid. When this happens, the pleural tube can be removed. Note that spontaneous pleurodesis has been known to happen to about half of patients. To remove an IPC, the adhesives around the cuff must be loosened with a metallic groover director.
Methods of Chest Tube Removal: Water Seal Vs Suction
In the previous section, we mentioned in passing the two basic methods for CT removal: wall suction or water seal. The main difference between the two is when suction is removed. With a suction procedure, the suction remains in the CT.
In the water seal method (preferred), suction is removed and the CT employs a water seal for a fixed time (e.g., 18 to 24 hours). If a chest x-ray shows that neither air nor fluid has accumulated, the CT is removed.
The technique employed for CT extraction is at the discretion of the attending physician based on previous training and preference. Those who favor the suction method believe that it prevents air from re-entering the pleural cavity from the chest wall and small system leaks. It also reduces the need for radiography.
On the other hand, clinicians who prefer the water seal method are of the opinion that it reduces the incidence of recurrent PTX. If pneumothorax recurs, it would require another thoracostomy which can significantly lengthen hospitalization.
A study published in the Journal of Trauma sought to explore the validity of these beliefs and how they affected the length of patients’ hospital stays. Patients were divided between water seal and no water seal groups. After undergoing their respective removal methods, 1.4% of the water seal group experienced recurring PTX while 9% of the non-water seal group had PTX. This provides some credence to the perception that the water seal method makes recurring PTX less likely. 6% of patients in the non-water seal group had to have their tubes reinserted while only 1% from the water seal group required CT reinsertion.
In the end, the empirical study concluded that there were no significant differences in the length of stay or how long the chest tubes remained inserted among patients with chest injuries. It’s also interesting to note that those who required CT reinsertion stayed in the hospital twice as long as patients who did not.
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Younes,R. Gross,J. Aguiar,S. Haddad,F. Deheinzelin, D. When to remove a chest tube? A randomized study with subsequent prospective consecutive validation Dis. 2002; 195 (5): 658-62.
Martino,K. Merrit,S. Boyakye, K. Sernas, T. Koller, C. Hauser, J. Lavery, R. Livingston, D. Prospective randomized trial of thoracostomy removal algorithms. Trauma Dis. 1999; 46(3): 372-3.