What are the management guidelines for chest tube output in hemothorax?

Management Guidelines for Chest Tube Output in Hemothorax

For hemothorax management, chest tube removal can be considered when drainage output is less than 200 mL per 24 hours, with higher output volumes (>1500 mL in 24 hours) warranting urgent surgical intervention. 1, 2

Initial Assessment and Chest Tube Management

Chest Tube Selection

• Small-bore chest tubes (14F or smaller) are recommended for initial drainage of pleural infection 3
• For hemothorax specifically:
  • Large-bore chest tubes are generally required for draining viscous pleural liquids such as blood 1
  • Unstable patients and those at risk for large pleural air leaks should be managed with 24F to 28F chest tubes 3

Monitoring Chest Tube Output

• Quantitative thresholds for intervention:
  • >1500 mL in 24 hours: Urgent thoracotomy is indicated regardless of injury mechanism 2
  • >200-500 mL/hour for 2-4 consecutive hours: Consider surgical intervention
  • <200 mL/24 hours: Safe threshold for chest tube removal consideration 1

Decision Algorithm for Hemothorax Management

1. High-Volume Output (Emergency Scenario)

• If chest tube output exceeds 1500 mL within 24 hours:
  • Immediate surgical consultation
  • Prepare for urgent thoracotomy
  • Risk of death increases linearly with total chest hemorrhage 2
  • Mortality risk at 1500 mL blood loss is 3 times greater than at 500 mL 2

2. Moderate Output (200-1500 mL/24 hours)

• Continue chest tube drainage
• Monitor vital signs, hemoglobin levels, and coagulation parameters
• Consider video-assisted thoracoscopic surgery (VATS) for retained hemothorax
  • VATS is recommended over thrombolytic therapy for retained hemothorax 4
  • Early VATS (≤4 days) is preferred over late VATS (>4 days) 4

3. Low Output (<200 mL/24 hours)

• Consider chest tube removal if:
  • Stable vital signs
  • No evidence of ongoing bleeding
  • Complete lung re-expansion on imaging
  • No air leak

Management of Persistent Air Leaks with Hemothorax

• For patients with persistent air leaks who are not surgical candidates, chemical pleurodesis may be considered 3
• Preferred agents include:
  • Doxycycline (good consensus)
  • Talc (very good consensus) 3

Chest Tube Removal Protocol

1. Ensure output is <200 mL/24 hours 1
2. Consider clamping the chest tube 5-12 hours after the last evidence of an air leak (though 41% of experts never clamp chest tubes) 3
3. Obtain a chest radiograph 13-23 hours after the last evidence of an air leak 3
4. If no recurrence of pneumothorax or significant fluid accumulation, proceed with tube removal

Follow-up Recommendations

• All patients should be followed up by a respiratory physician to ensure resolution 3
• Consider follow-up chest imaging 2-4 weeks after chest tube removal 3
• For patients with spontaneous hemothorax, investigate underlying causes

Pitfalls and Caveats

• Never clamp a bubbling chest tube (actively draining air) as this may lead to tension pneumothorax 5
• Be mindful of alternative diagnoses that can mimic pleural effusions with low pH and potential for loculations (e.g., rheumatoid effusion, malignant effusions) 3
• Delays in thoracotomy for high-volume hemothorax are associated with increased mortality 2
• Blunt trauma patients often experience longer delays to thoracotomy than penetrating trauma patients (4.4 vs 1.6 hours), which may contribute to worse outcomes 2

By following these guidelines, clinicians can optimize the management of patients with hemothorax, minimizing complications and improving outcomes.