From the Guidelines
For pneumothorax, the best initial chest tube size is typically 10-14 French (Fr), as there is no evidence that large tubes are any better than small tubes in the management of pneumothoraces. According to the BTS guidelines for the management of spontaneous pneumothorax 1, primary success rates of 84–97% were recorded using drains of 7–9 F gauge, suggesting that smaller calibre chest tubes are just as effective. The use of small (10–14 F) systems is recommended initially, with the option to replace with a larger tube if there is a persistent air leak or other complications. Some key factors to consider when choosing a chest tube size include:
- The presence of pleural fluid, which may require a larger tube
- The presence of a large air leak, which may exceed the capacity of smaller tubes
- The use of an indwelling small lumen Teflon catheter (2 mm) inserted “over needle and guidewire” attached to a flutter valve, which has been shown to be successful in 27 of 28 patients with a mean drainage time of 48 hours 1. It's also worth noting that chemical pleurodesis is still possible through smaller tubes, including indwelling catheter systems 1. Overall, the choice of chest tube size should be based on the specific clinical situation, with a trend toward using smaller tubes when appropriate due to improved patient comfort and similar efficacy for air drainage.
From the Research
Chest Tube Size for Pneumothorax
- The optimal chest tube size for pneumothorax is still a matter of debate, with different studies suggesting different sizes 2, 3, 4, 5, 6.
- Large-bore chest tubes are generally required for patients with pneumothoraces, regardless of etiology, if the patient is mechanically ventilated, or for patients requiring drainage of viscous pleural liquids such as blood 2.
- Small-bore chest tubes (≤14F) are generally recommended as the first-line therapy for spontaneous pneumothorax in non-ventilated patients and pleural effusions in general, with the possible exception of hemothoraces and malignant effusions 3.
- A study comparing 28-32 French chest tube size with 36-40 French chest tube size in trauma patients found no difference in clinically relevant outcomes, including retained hemothoraces, the need for additional tube insertion, and invasive procedures 4.
- Another study found that emergency physicians did not choose tube size depending on patient sex, body size, or situation, and that even with a <28 Fr tube placed in chest trauma patients, the risk of residual hemo/pneumothorax and tube occlusion did not increase, and drainage was effective 5.
- A laboratory study measuring chest tube drainage found that the 28 French chest tube exhibited high and consistent velocity, while smaller tubes were slower and more variable, and larger tubes offered only slightly higher flowrates 6.
Recommendations
- The choice of chest tube size should be based on the individual patient's needs and the specific clinical situation 2, 3.
- A 28 French chest tube may be a good balance of reasonable size and high flowrate, and is likely the optimal size for most clinical applications 6.
- However, the optimal chest tube size may vary depending on the specific clinical situation, and further studies are needed to provide evidence-based answers to the many questions remaining regarding chest tube placement, ongoing management, and removal 2, 3, 4, 5, 6.