From the Guidelines
The management plan for chest tubes after spontaneous pneumothorax should prioritize the application of suction after 48 hours for persistent air leak or failure of the pneumothorax to re-expand, using high volume, low pressure systems, as recommended by the British Thoracic Society guidelines 1. The optimal management of patients with ongoing air leak involves several treatment options, including application of thoracic suction, converting to larger-bore chest drain, blood patch or chemical pleurodesis, endobronchial valves or thoracic surgery, as outlined in the British Thoracic Society guideline for pleural disease 1. Key considerations in the management of chest tubes after spontaneous pneumothorax include:
- The use of small (10–14 F) chest tube systems initially, with the option to replace with a larger tube if necessary 1
- The application of suction after 48 hours for persistent air leak or failure of the pneumothorax to re-expand, using high volume, low pressure systems 1
- The importance of specialist nursing experience and monitoring in patients requiring suction 1
- The consideration of chemical pleurodesis or surgical intervention for persistent air leaks lasting more than 3-5 days 1
- The need for pain management, including scheduled acetaminophen, NSAIDs, and opioids as needed, as well as follow-up chest X-rays to ensure no recurrence after chest tube removal. Overall, the management plan should prioritize the patient's safety, comfort, and outcomes, while minimizing hospitalization duration and discomfort from prolonged chest tube placement.
From the Research
Management Plan for Chest Tubes after Spontaneous Pneumothorax
The management of chest tubes after spontaneous pneumothorax involves several key considerations, including the type of chest tube used, the method of insertion, and the approach to drainage and removal.
- Type of Chest Tube: Small-bore chest tubes (≤14F) are generally recommended as the first-line therapy for spontaneous pneumothorax in non-ventilated patients 2.
- Method of Insertion: Chest tube insertion should be guided by imaging, either bedside ultrasonography or computed tomography, and the Seldinger technique should be used instead of the trocar technique 2.
- Approach to Drainage: The use of underwater seal or digital drainage systems can facilitate informed decision-making regarding tube removal 2, 3.
- Removal of Chest Tube: The optimal timing for tube removal is still a matter of controversy, but a drain-clamping test before tube withdrawal is generally not advocated 2.
- Complications: Common complications of small-bore drains include pain, drain blockage, and accidental dislodgment, while more serious complications include organ injury, hemothorax, infections, and re-expansion pulmonary edema 2, 4, 5.
Specific Considerations
- Re-expansion Pulmonary Edema: This is a rare but potentially life-threatening complication of chest tube insertion, and risk factors include rapid re-expansion of the lung, young patient age, and a large pneumothorax persisting longer than 24 hours 4, 5.
- Underwater Seal: Early underwater seal appears to be safe for treating iatrogenic and spontaneous pneumothoraces, and can achieve comparable frequencies of early chest tube removal and avoidance of operation compared with traditional management 3.
- Serial-Steps Approach: A serial-steps approach with a single system (small-calibre catheter/Heimlich valve) can be effective in managing primary spontaneous pneumothorax, with a high success rate and low recurrence rate 6.