What are the criteria and protocol for removing an intercostal (chest) tube?

Intercostal Tube Removal Protocol

Intercostal tubes should be removed within 12-72 hours after sclerosant administration when there is full lung re-expansion and satisfactory evacuation of pleural fluid on chest radiograph, provided fluid drainage is less than 250 ml/day. 1

General Criteria for Chest Tube Removal

Primary Criteria

• Complete lung re-expansion confirmed on chest radiograph
• Absence of air leak (no bubbling in water seal device)
• Minimal fluid drainage (<250 ml/day for pleurodesis cases, <150-200 ml/day for other cases)

Procedural Steps Before Removal

1. Confirm Resolution of Initial Problem:

   • For pneumothorax: Complete lung re-expansion with no air leak
   • For pleural effusion: Adequate drainage with minimal residual fluid
   • For post-pleurodesis: 12-72 hours after sclerosant administration with minimal drainage

2. Discontinue Suction:

   • If suction has been applied, discontinue it first before considering tube removal 1
   • Observe for 4-24 hours without suction to ensure stability

3. Chest Radiograph Confirmation:

   • Obtain a chest radiograph after discontinuing suction
   • Confirm complete lung expansion and minimal residual fluid/air

Specific Protocols by Clinical Scenario

For Post-Pleurodesis Patients

• Clamp tube for 1 hour after sclerosant administration 1
• Remove tube within 12-72 hours if:
  • Lung remains fully expanded
  • Daily drainage <250 ml/day
  • Satisfactory evacuation of pleural fluid on chest radiograph

For Pneumothorax Patients

• Staged removal process to ensure air leak has resolved 1
• First stage: Discontinue suction and confirm no air leak
• Second stage: Obtain chest radiograph 5-12 hours after last evidence of air leak
• Remove tube if pneumothorax has not recurred 1

For Post-Surgical Patients

• Can safely remove chest tube when drainage is ≤200 ml/day of uninfected fluid 2
• Research shows no increased risk of fluid reaccumulation with this threshold compared to more conservative thresholds (100-150 ml/day)

Technical Aspects of Tube Removal

1. Patient Preparation:

   • Consider premedication with atropine to prevent vasovagal reaction 1
   • Provide adequate analgesia before procedure
   • Position patient appropriately (usually semi-recumbent)

2. Removal Technique:

   • Remove suture securing the tube
   • Withdraw tube while patient holds breath in full inspiration or full expiration 1
   • Immediately seal the wound with remaining sutures
   • Apply occlusive dressing

3. Post-Removal Monitoring:

   • Obtain post-removal chest radiograph to confirm continued lung expansion
   • Monitor vital signs for 1-2 hours after removal
   • Observe for signs of pneumothorax or fluid reaccumulation

Special Considerations

For Malignant Pleural Effusions

• In patients with mesothelioma, consider prophylactic radiotherapy to the chest tube site after removal to prevent tumor seeding 1

For Early Removal Programs

• In selected cases (e.g., VATS lung biopsy), early removal (<1 hour post-procedure) may be safe if:
  • Complete lung expansion is confirmed
  • No air leak is present
  • Drainage is minimal 3

Common Pitfalls to Avoid

• Premature removal: Removing tube before complete resolution of pneumothorax or before drainage has adequately decreased
• Unnecessary prolonged drainage: Keeping tube in place longer than needed increases risk of infection and patient discomfort 1
• Improper clamping: Clamping chest tubes inappropriately can lead to tension pneumothorax in patients with ongoing air leaks
• Inadequate post-removal monitoring: Failure to obtain post-removal imaging or monitor for recurrence

By following this structured approach to intercostal tube removal, clinicians can optimize patient outcomes while minimizing complications and unnecessary prolonged hospitalization.