From the Guidelines
Chest tube thoracostomy (CTT) removal after tuberculous pleural effusion should be considered when daily drainage decreases to less than 100-150 mL per 24 hours, the lung has fully re-expanded on chest X-ray, and there is no evidence of air leak or ongoing infection. The decision to remove the CTT is based on clinical improvement and resolution of the pleural effusion, rather than the use of corticosteroids, as studies have shown that prednisone administration does not reduce the development of residual pleural thickening 1. Key considerations for CTT removal include:
- Daily drainage of less than 100-150 mL per 24 hours
- Full lung re-expansion on chest X-ray
- No evidence of air leak or ongoing infection
- Clinical improvement with resolving fever, decreasing inflammatory markers, and effective anti-tuberculosis therapy Before removal, it is essential to ensure the patient is clinically improving with effective anti-tuberculosis therapy, typically including isoniazid, rifampin, ethambutol, and pyrazinamide, as recommended by the American Thoracic Society 1. The procedure should be performed at end-expiration or during Valsalva maneuver to prevent air entry, followed by immediate application of an occlusive dressing. After removal, a post-procedure chest X-ray should be obtained to confirm lung expansion and absence of pneumothorax. Patients should continue their full course of anti-TB medications (typically 6 months) after tube removal to ensure complete resolution of the infection, as recommended for treating pleural tuberculosis 1.
From the Research
Indications for Removal of Chest Tube (CTT) after TB Pleural Effusion
- The decision to remove a chest tube after TB pleural effusion is based on the volume of drainage, with a recommended threshold of 200 mL/day of uninfected drainage 2.
- A study found that increasing the threshold of daily drainage to 200 mL before removing the chest tube did not markedly affect drainage, hospitalization time, or overall costs, nor did it increase the likelihood of major pleural fluid reaccumulation 2.
- The treatment of TB pleural effusion typically involves a regimen of antituberculous drugs, such as isoniazid, rifampin, and pyrazinamide, for a period of 6 months 3, 4, 5.
- The presence of drug resistance in TB pleural effusion patients may require modification of the treatment regimen, with the use of cultures or molecular methods with pleural biopsies to guide therapy 6.
- The removal of the chest tube is generally considered when the drainage is less than 200 mL/day and there is no evidence of air leaks or other complications 2.
Considerations for CTT Removal
- The volume of drainage is an important factor in determining when to remove the chest tube, with a threshold of 200 mL/day considered safe for removal 2.
- The type of pleural effusion, including the presence of infection or air leaks, may influence the decision to remove the chest tube 2.
- The patient's overall clinical condition, including the presence of symptoms such as fever or chest pain, should be taken into account when deciding when to remove the chest tube 3, 4, 5.