What is the indication for chest drain insertion in a patient with pleural effusion?

From the Guidelines

Chest drains for pleural effusions should initially utilize small-bore catheters (10-14F) due to reduced patient discomfort, ease of placement, and comparable pleurodesis success rates, as supported by the BTS guidelines 1. When managing pleural effusions, the following key points should be considered:

• Indications for chest drains include symptomatic, large (typically >1-1.5L), or diagnostic sampling requirements
• Small-bore catheters (10-14F) are preferred over large-bore tubes unless there's evidence of blood or thick fluid
• The procedure involves sterile preparation, local anesthesia, and insertion in the "safe triangle" or the 4th-5th intercostal space in the mid-axillary line
• Ultrasound guidance is recommended to assist in drainage, particularly for small or loculated effusions, to reduce complications such as pneumothorax and improve accuracy 1
• The drain should be connected to an underwater seal system with suction (typically 10-20 cmH2O) applied if needed for lung expansion
• Chest drains should remain in place until fluid drainage decreases to <150-200 mL/day, with daily chest X-rays to monitor progress
• Complications include pain, infection, bleeding, pneumothorax, and organ injury
• Pleural effusions often recur after drainage alone, so addressing the underlying cause (heart failure, malignancy, infection) is essential
• For recurrent malignant effusions, pleurodesis with talc or doxycycline may be considered to prevent reaccumulation by creating pleural adhesions.

From the Research

Chest Drain and Pleural Effusion

• A chest drain, also known as a thoracostomy tube, is used to remove fluid, air, or blood from the pleural space to help the lung expand and to relieve symptoms such as shortness of breath and chest pain 2, 3.
• Pleural effusion is an excessive accumulation of fluid in the pleural space, which can be caused by various disorders, including lung or pleura disorders, or systemic disorders 2.
• The etiology of pleural effusion remains unclear in nearly 20% of cases, and thoracocentesis should be performed for new and unexplained pleural effusions to determine the underlying cause 2.

Diagnosis and Treatment

• The diagnostic evaluation of pleural effusion includes chemical and microbiological studies, as well as cytological analysis, which can provide further information about the etiology of the disease process 2.
• Laboratory testing helps to distinguish pleural fluid transudate from an exudate, and immunohistochemistry provides increased diagnostic accuracy 2.
• Transudative effusions are usually managed by treating the underlying medical disorder, while exudative effusions require specific treatment depending on the underlying etiology 2, 4.
• Malignant effusions are usually drained to palliate symptoms and may require pleurodesis to prevent recurrence 2, 4.

Management of Pleural Effusions

• The management of pleural effusions depends on the underlying cause, and a systematic approach is necessary for rapid recognition, clinical cause identification, and definitive management of potential urgent pleural effusions 3.
• Point-of-care ultrasound is recommended for evaluating the pleural space and guiding thoracentesis to reduce complications 5.
• Computed tomography of the chest can exclude other causes of dyspnea and suggest complicated parapneumonic or malignant effusion 5.
• Indwelling pleural catheters can be used for malignant pleural effusions, and pleuroscopy can be used as a diagnostic and therapeutic modality 6, 4.