What are the guidelines for removing mediastinal chest tubes?

Guidelines for Removing Mediastinal Chest Tubes

Mediastinal chest tubes should be removed when drainage becomes macroscopically serous and is less than 100-200 mL per 24 hours with no evidence of air leak. 1

Criteria for Safe Chest Tube Removal

Primary Requirements

• Drainage volume less than 100-200 mL per 24 hours 1, 2
• Serous (non-bloody) appearance of drainage 1
• Complete resolution of air leak (if present) 3
• Complete lung expansion on chest radiograph 3

Timing Considerations

• For cardiac surgery patients:

  • Remove as soon as drainage becomes macroscopically serous 1
  • Goal is removal by postoperative day 1 1
  • Typical removal occurs when drainage is less than 100 mL over 8 hours 1

• For thoracic surgery patients:

  • Can safely use 200 mL/day threshold without increasing risk of fluid reaccumulation 2
  • Early removal (within 24 hours) is safe if no air leak is present 4

Procedure for Removal

1. Pre-removal assessment:

   • Confirm drainage is below threshold (100-200 mL/24 hours)
   • Verify drainage is serous in appearance
   • Ensure no air leak is present
   • Confirm complete lung expansion on chest radiograph

2. Discontinue suction (if being used) prior to removal 3

3. Removal technique:

   • Have patient perform Valsalva maneuver during removal to prevent air entry
   • Remove tube quickly during expiration phase
   • Immediately apply occlusive dressing

4. Post-removal monitoring:

   • Observe for signs of respiratory distress
   • Monitor for evidence of fluid reaccumulation or pneumothorax

Special Considerations

Air Leaks

• Traditionally, presence of air leak has been a contraindication for chest tube removal 5
• However, research suggests tubes can be safely removed even with persistent air leak if:
  • Patient has been asymptomatic for at least 14 days
  • No subcutaneous emphysema is present
  • Pleural space deficit has not increased in size 5

Tube Size

• Smaller tubes (10-14F) are as effective as larger tubes (20-24F) for most applications 1
• Small silastic drains (10mm Blake drains) have been shown to be as effective as traditional large-bore tubes for mediastinal drainage with less pain and better mobility 6

Drainage Thresholds

• Research shows that using a 200 mL/day threshold is safe and does not increase risk of significant fluid reaccumulation compared to more conservative thresholds (100 or 150 mL/day) 2
• This higher threshold can potentially reduce drainage time and hospital stay

Potential Complications of Premature Removal

• Cardiac tamponade due to retained blood 1
• Hemothorax or pneumothorax requiring reinsertion 4
• Pleural effusion requiring thoracentesis 2

Pitfalls to Avoid

1. Never clamp a bubbling chest tube (indicates active air leak) 3

2. Avoid chest tube stripping or milking as meta-analyses show this is ineffective and potentially harmful 1

3. Don't break sterile field to access inside of chest tubes to clear clots, as this increases infection risk 1

4. Don't delay removal when criteria are met, as prolonged chest tube placement increases risk of infection and patient discomfort 1

By following these evidence-based guidelines, mediastinal chest tubes can be safely removed at the appropriate time, minimizing patient discomfort while preventing complications from premature removal.