From the Guidelines
Chest tube insertion is indicated for pneumothorax when there is a large or symptomatic air collection in the pleural space, as stated in the most recent guideline from 2023 1.
Indications for Chest Tube Insertion
The indications for chest tube insertion in pneumothorax include:
- Tension pneumothorax (after needle decompression)
- Pneumothorax greater than 2-3 cm from lung apex to cupola on chest X-ray
- Any symptomatic pneumothorax causing respiratory distress, hypoxemia, or hemodynamic compromise
- Bilateral pneumothoraces
- Pneumothorax in mechanically ventilated patients
- Traumatic pneumothorax with ongoing air leak
Procedure and Management
The procedure involves inserting a tube (typically 10-14 French for pneumothorax, as recommended by the BTS guidelines 1) through the chest wall into the pleural space, usually at the 4th or 5th intercostal space in the mid-axillary line. The tube is then connected to a drainage system with water seal and often suction (typically -10 to -20 cm H2O). Local anesthesia with 1-2% lidocaine is essential, and post-procedure chest X-ray is required to confirm proper placement and lung re-expansion.
Special Considerations
For small, asymptomatic primary spontaneous pneumothoraces (less than 2 cm), observation or simple aspiration may be sufficient, as stated in the BTS guidelines for the management of spontaneous pneumothorax 1. However, in patients with cystic fibrosis, larger pneumothoraces require a chest drain, and interventions such as pleurectomy, pleural abrasion, and pleurodesis may be necessary to reduce recurrence, as recommended in the 2023 British Thoracic Society guideline for pleural disease 1.
Key Recommendations
- Chest tube insertion should be performed under the guidance of a respiratory physician or thoracic surgeon, with careful monitoring of the patient's symptoms and lung function.
- The chest tube should not be clamped unless under the supervision of a respiratory physician or thoracic surgeon, and the patient should be managed in a specialist ward with experienced nursing staff.
- If a patient with a clamped drain becomes breathless or develops subcutaneous emphysema, the drain must be immediately unclamped and medical advice sought.
From the Research
Indications for Chest Tube Insertion in Pneumothorax
The indications for chest tube insertion in pneumothorax can be summarized as follows:
- Symptomatic pneumothorax: Chest tube insertion is often required for patients with symptomatic pneumothorax, especially those with large pneumothoraces (greater than 35%) 2.
- Traumatic pneumothorax: Chest tube insertion is commonly used to treat traumatic pneumothorax, although smaller pigtail catheters may be effective and associated with less tube-site pain 3, 4.
- Pneumothorax requiring decompression: Chest tube insertion can be used to decompress pneumothoraces, especially those that are large or symptomatic 2, 5.
- Pneumothorax with underlying conditions: Patients with underlying conditions, such as emphysema, may require chest tube insertion for pneumothorax treatment 6.
Factors Influencing Chest Tube Placement
Several factors can influence the decision to place a chest tube in patients with pneumothorax, including:
- Patient position during biopsy: The supine position may increase the risk of pneumothorax requiring chest tube placement 6.
- Size and location of the pneumothorax: Larger pneumothoraces or those in certain locations may require chest tube insertion 2, 3.
- Presence of underlying conditions: Patients with underlying conditions, such as emphysema, may require chest tube insertion for pneumothorax treatment 6.
Types of Chest Tubes
Different types of chest tubes can be used to treat pneumothorax, including:
- Large-bore chest tubes (22-32-F): Traditionally used to treat pneumothorax, but may be associated with more pain and trauma 2, 3.
- Small-caliber catheters (7,8.2, and 9.4 F): May be effective for decompressing pneumothoraces and can be inserted expeditiously by radiologists 2.
- Pigtail catheters (14-F): May be associated with less tube-site pain and can be effective for treating traumatic pneumothorax 3, 4.