What is the recommended chest tube size for tube thoracostomy in adults and pediatric patients?

Recommended Chest Tube Sizes for Tube Thoracostomy

For adult patients, initial drainage of pleural infection or pneumothorax should be undertaken using a small bore chest tube (14F or smaller), while pediatric patients should receive size-appropriate tubes based on age (infant: 10-12F; child: 16-24F). 1

Adult Chest Tube Sizing

For Pleural Infection/Empyema

• Small bore tubes (≤14F) are recommended as first-line treatment 1
  • The British Thoracic Society (BTS) 2023 guidelines provide a conditional recommendation for small bore tubes based on consensus
  • No evidence of difference in mortality, need for surgery, or length of hospital stay compared to larger tubes
  • Smaller tubes are associated with less post-treatment pain

For Pneumothorax

• Small tubes (10-14F) are recommended initially 1
  • BTS guidelines explicitly state that large tubes (20-24F) are not recommended for initial management
  • Primary success rates of 84-97% have been reported with small tubes (7-9F)
  • Small-bore catheter systems have shown comparable drainage times to larger systems

For Trauma Cases

• Small tubes (20-22F) are effective for most traumatic pneumothoraces/hemothoraces 2, 3
  • Recent studies show no significant difference in complications or need for additional procedures between small (20-22F) and large tubes (28F)
  • For massive hemothorax with active bleeding, 28F tubes may provide optimal flow characteristics 4

Pediatric Chest Tube Sizing

Age-Based Recommendations

• Infant: 10-12F 1
• Child: 16-24F 1
• Adult sizes for adolescents: 28-40F 1

For Pleural Infection in Children

• Small catheters (8-12F) are preferred 1
  • BTS pediatric guidelines note that smaller tubes are associated with better patient comfort and tolerance
  • Post-hoc analysis showed shorter hospital stays with small percutaneous catheters (mean 10.5F) compared to larger surgical drains (mean 20.1F)

Clinical Considerations for Tube Selection

Factors Affecting Size Selection

1. Patient condition: Unstable patients may require larger tubes (24-28F) 1
2. Indication:
   • Pneumothorax: Small tubes (≤14F) are adequate 1
   • Empyema: Small tubes (≤14F) are effective 1
   • Hemothorax: Consider 20-28F depending on bleeding severity 2, 3, 4
3. Mechanical ventilation: Patients requiring mechanical ventilation may need larger tubes (24-28F) due to risk of large air leaks 1

Insertion Technique

• Small-bore tubes are typically inserted using the Seldinger technique (guidewire method)
• Larger tubes are often placed using blunt dissection
• Sterile technique is essential regardless of tube size 1

Potential Complications

By Tube Size

• Large tubes: Greater pain, more tissue trauma, cosmetic concerns
• Small tubes: Potential for occlusion with thick secretions or blood clots

Overall Complication Rates

• No significant difference in rates of empyema, retained hemothorax, or need for additional procedures between small and large tubes 3, 5
• Pain scores do not differ significantly between small (28-32F) and large (36-40F) tubes 5

Special Considerations

Tracheostomy Tubes

• Should extend at least 2cm beyond the stoma and remain 1-2cm above the carina 1
• Diameter selection should minimize work of breathing while avoiding tracheal wall damage

Cuffed vs. Uncuffed Tubes

• For tracheostomy, cuffed tubes may be used to minimize aspiration risk or for mechanical ventilation 1
• Cuff pressures should be kept below 20 cm H₂O to maintain airway epithelium perfusion

Summary Algorithm for Chest Tube Size Selection

1. Adult with pneumothorax: Start with 10-14F tube
2. Adult with pleural infection: Use ≤14F tube
3. Adult with traumatic hemothorax:
   • Stable patient: 20-22F tube
   • Unstable or massive bleeding: Consider 28F tube
4. Pediatric patients:
   • Infant: 10-12F
   • Child: 16-24F
   • Adolescent: Size according to adult recommendations

Remember that proper positioning and management of the chest tube are as important as size selection for achieving optimal outcomes.