From the Guidelines
A chest tube can be removed when drainage has decreased to less than 300 mL/24 hours and there is no air leak present, as evidenced by recent studies 1. This recommendation is based on the most recent and highest quality study, which demonstrated the equivalence of drain removal in the absence of air leaks for fluid drainage < 300 mL/24h compared to fluid drainage < 100 mL/24h in terms of complications and re-drainage 1. The decision to remove a chest tube should always be made by a healthcare provider, usually a surgeon or pulmonologist, who will assess these criteria, including the presence of air leaks, the volume and appearance of the fluid drained over 24 hours, and the persistence of pleural effusion on chest x-ray. Some key points to consider when removing a chest tube include:
- The absence of air leaks
- The volume of fluid drainage, which should be less than 300 mL/24 hours
- The appearance of the fluid drained
- The presence of pleural effusion on chest x-ray
- The patient's overall clinical condition and recovery Before removal, pain medication is often administered since the procedure can be uncomfortable, and during removal, the patient will typically be asked to perform the Valsalva maneuver to prevent air from entering the pleural space as the tube is withdrawn. After removal, an occlusive dressing is applied to the site, and a follow-up chest X-ray is usually obtained to ensure no complications have occurred, as supported by the guidelines on enhanced recovery after pulmonary lobectomy 1. It's worth noting that earlier guidelines suggested removing the chest tube when pleural fluid drainage is < 1 ml/kg/24 h 1, but the more recent study 1 provides stronger evidence for the 300 mL/24 hours threshold.
From the Research
Criteria for Chest Tube Removal
The decision to remove a chest tube is based on several factors, including the amount of drainage, the presence of an air leak, and the patient's overall condition.
- A study published in the Journal of the American College of Surgeons 2 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.
- Another study published in The Annals of thoracic surgery 3 suggested that chest tubes can be safely removed even if the patients have a pneumothorax, if the patients have been asymptomatic, have no subcutaneous emphysema after 14 days on a portable device at home, and the pleural space deficit has not increased in size.
- A randomized clinical trial published in Bulletin of emergency and trauma 4 found that the removal of chest tube in patients under ventilation within 5-7 days after its insertion is safe without any complications.
Drainage Volume Thresholds
Different studies have suggested various drainage volume thresholds for chest tube removal.
- A study published in the Journal of the American College of Surgeons 2 recommended a threshold of 200 mL/d for uninfected pleural fluid with no evidence of air leaks.
- A study published in The Journal of thoracic and cardiovascular surgery 5 found that chest tubes can be removed with up to 450 mL/day of nonchylous drainage after pulmonary resection.
- Another study published in Bulletin of emergency and trauma 4 used a threshold of less than 300 mL of drainage for chest tube removal.
Air Leaks and Pneumothorax
The presence of an air leak or pneumothorax is not always a contraindication for chest tube removal.
- A study published in The Annals of thoracic surgery 3 found that chest tubes can be safely removed even if the patients have a pneumothorax, if certain criteria are met.
- A study published in Bulletin of emergency and trauma 4 found that complications were not significantly different between patients with and without air leaks.