From the Guidelines
A chest tube should be placed in a pneumothorax when it is large (>2-3 cm between the chest wall and lung edge), causing respiratory distress, or when it is a tension pneumothorax, as recommended by the most recent guidelines 1.
Indications for Chest Tube Placement
The following are indications for chest tube placement:
- Symptomatic primary spontaneous pneumothorax
- Secondary pneumothorax of any size
- Tension pneumothorax after needle decompression
- Traumatic pneumothorax
- Persistent air leak after aspiration
Procedure for Chest Tube Placement
The procedure involves inserting a tube (typically 16-28 French for adults) through the chest wall into the pleural space, usually at the 4th or 5th intercostal space in the mid-axillary line. The tube is connected to a drainage system with water seal and suction (typically -10 to -20 cm H2O). Local anesthesia with 1-2% lidocaine is administered before insertion, as suggested by previous guidelines 1.
Management of Chest Tube
The tube remains in place until the air leak resolves and the lung fully expands, typically 2-4 days, confirmed by chest X-ray. Small, stable pneumothoraces in asymptomatic patients may be observed without chest tube placement, and some patients may be candidates for simple aspiration instead, as noted in earlier studies 1.
Key Considerations
It is essential to consider the size of the pneumothorax, the presence of respiratory distress, and the risk of complications when deciding on chest tube placement. The use of small-caliber chest tubes and the application of suction should be guided by the patient's clinical condition and the presence of a persistent air leak, as recommended by the British Thoracic Society guidelines 1.
From the Research
Indications for Chest Tube Placement in Spontaneous Pneumothorax
- The decision to place a chest tube in spontaneous pneumothorax should be guided by the patient's symptoms, rather than the size of the pneumothorax 2
- Small pneumothoraces can be managed conservatively, while large or symptomatic pneumothoraces may require manual aspiration or insertion of a small-bore catheter 3
- Definitive measures to prevent recurrence, such as pleurodesis, are recommended after the first recurrence of pneumothorax 3
Factors Influencing Chest Tube Placement
- The size of the pneumothorax and the presence of symptoms are key factors in determining the need for chest tube placement 3, 4
- The type of pneumothorax (primary or secondary) also influences the management approach, with secondary pneumothoraces typically requiring more aggressive treatment 3
- The presence of an air leak can also impact the decision to place a chest tube, with larger air leaks and larger pneumothoraces increasing the likelihood of failure of water seal 4
Chest Tube Management
- Small-bore chest tubes are as effective as large-bore chest tubes and are associated with fewer complications 2, 5
- Passive drainage and the use of a Heimlich valve or water-seal device can allow for out-of-hospital follow-up for selected patients 2, 5
- The use of ultrasound guidance during central vascular access procedures can help prevent pneumothorax 6