What are the guidelines for managing a chest tube in a patient with pleural effusion?

Guidelines for Managing a Chest Tube in Patients with Pleural Effusion

Small bore chest tubes (10-14F) should be the initial choice for draining pleural effusions, as they are less traumatic to insert, more comfortable for patients, and have similar success rates to large bore tubes. 1

Chest Tube Selection and Insertion

Tube Size

• Small bore catheters (10-14F) are recommended as first-line for most pleural effusions 1, 2
• Large bore tubes (24-32F) may be considered in specific situations:
  • Hemothorax
  • Malignant effusions when immediate pleurodesis is planned
  • After failure of small bore tubes in cases with very large air leaks 2

Insertion Technique

• Ultrasound guidance should be used for all thoracentesis and chest tube placements 1
  • Reduces pneumothorax risk (1.0% vs 8.9% without guidance) 1
  • Helps identify optimal insertion site
• Avoid trocar technique (dangerous and outdated) 2
• Use either:
  • Seldinger technique for small bore tubes
  • Blunt dissection for larger tubes (>24F) 2
• Insertion site should be determined by ultrasound to identify the optimal location 1
• For malignant effusions, the tube should ideally be positioned at the paravertebral gutter in the posterobasal area for maximum drainage efficiency 3

Chest Tube Management

Initial Management

1. Confirm proper tube position with chest radiograph after insertion 1
2. Connect tube to appropriate drainage system:
   • Underwater seal
   • Electronic drainage system
   • Vacuum bottles (for indwelling pleural catheters) 2
3. For malignant effusions, controlled evacuation is critical to prevent re-expansion pulmonary edema 1
   • Limit initial drainage to 1-1.5L 1
   • Consider clamping the drain for 1 hour after removing 10ml/kg in children 1

Ongoing Management

• Maintain the drainage system below the level of the patient's chest at all times 1
• Monitor for:
  • Fluid output (document amount and characteristics)
  • Air leaks
  • Tube position and patency 4
• Apply suction only if gravity drainage is ineffective 2
  • For malignant effusions, maintain at 20cm H₂O suction after unclamping the chest tube 1
• If drainage suddenly stops:
  • Check for tube obstruction (blockage or kinking)
  • Flush with sterile saline if needed 1
  • If tube remains blocked despite flushing, it should be removed and replaced if significant fluid remains 1

Chemical Pleurodesis (for Malignant Effusions)

If pleurodesis is planned:

1. Ensure complete lung expansion before proceeding
2. Administer premedication (analgesia/sedation)
3. Instill lidocaine (3mg/kg; maximum 250mg) into pleural space
4. Follow with sclerosant of choice (talc slurry 4-5g in 50ml normal saline is common)
5. Clamp tube for 1 hour and consider patient rotation for talc slurry
6. Unclamp and maintain on suction 1

Chest Tube Removal Criteria

• For non-malignant effusions:

  • Remove when clinical resolution is achieved 1
  • No evidence supports routine drain clamping before removal 2

• For malignant effusions after pleurodesis:

  • Remove when 24-hour drainage is ≤100-150ml 1
  • Typically within 12-72 hours if lung remains fully expanded 1

• For empyema or complicated parapneumonic effusions:

  • Consider intrapleural fibrinolytics (urokinase, streptokinase) for loculated effusions 1
  • Remove when clinical improvement and adequate drainage is achieved

Complications and Management

Common Complications

• Pain (manage with appropriate analgesia) 1, 2
• Drain blockage (flush with sterile saline) 1
• Accidental dislodgment (secure properly with commercial dressings) 2

Serious Complications

• Pneumothorax (can occur during insertion or after removal)
• Infection (maintain strict aseptic technique)
• Re-expansion pulmonary edema (prevent by controlled evacuation)
• Organ injury (avoid with image guidance) 2

Important Cautions

• Never clamp a bubbling chest tube (risk of tension pneumothorax) 1
• Immediately unclamp and seek medical advice if patient develops breathlessness or chest pain after clamping 1
• For persistent sepsis despite drainage and antibiotics, consider surgical referral 1

Special Considerations for Failed Drainage

If initial management fails:

• Obtain contrast-enhanced CT scan to evaluate for:
  • Loculations
  • Tube position
  • Pleural thickening ("fibrinous peel") 1
• Consider intrapleural fibrinolytics for loculated effusions 1
• For malignant effusions with trapped lung, consider indwelling pleural catheter rather than repeated pleurodesis attempts 1
• Early discussion with thoracic surgeon for persistent sepsis or organized empyema 1