Chest Drain Size for Small Haemothorax
For a small haemothorax, a small-bore chest tube (16F to 22F) is recommended as the appropriate size for effective drainage. 1
Chest Tube Size Selection
The appropriate chest tube size depends on the nature and volume of the pleural collection:
- Small haemothorax: 16F to 22F tubes are generally sufficient 1
- Large haemothorax: Larger tubes (24F to 28F) may be considered 1
- Very small collections: Small-bore catheters (≤14F) may be adequate for stable patients 2
While traditionally large-bore chest tubes (28-36 French) were recommended for traumatic haemothorax 3, recent evidence suggests that smaller tubes can be effective for small haemothorax collections. The American College of Chest Physicians recommends using smaller tubes (16F to 22F) for most cases, reserving larger tubes (24F to 28F) for large pneumothoraces, bronchopleural fistulas, or significant bleeding 1.
Insertion Technique
The insertion technique is as important as tube size selection:
- Preferred technique:
- Seldinger technique for smaller tubes
- Blunt dissection for tubes >24F 1
- Avoid: Trocar technique (outdated and dangerous) 1, 2
- Insertion site: 5th intercostal space in the midaxillary line 3
- Imaging guidance: Use ultrasound or CT guidance for placement 1
Drainage System Management
After insertion, proper management is essential:
- Connect to an underwater seal drainage system
- Initial approach: Water seal without suction 1
- If inadequate drainage occurs: Apply suction at 15-20 cm H₂O 3
- Obtain a chest radiograph after tube placement to confirm position and assess initial drainage 1
Important Considerations
Advantages of Smaller Tubes
- Less painful for patients
- Easier to insert
- Lower risk of trauma during insertion 4
When to Consider Larger Tubes
- Very large air leaks
- Massive haemothorax with active bleeding
- After ineffective trial with small-bore drains 2
- Presence of blood clots 4
Potential Complications to Monitor
- Pain (more common with larger tubes)
- Drain blockage (more common with smaller tubes)
- Accidental dislodgment
- Infection (approximately 1% of cases)
- Organ injury
- Re-expansion pulmonary edema (approximately 11% of cases) 1
Recent Innovations
A study evaluating an active tube clearance (ATC) system with a 20-Fr tube demonstrated superior drainage compared to standard 32-Fr tubes in an acute hemothorax model 5. This suggests that tube design may be as important as diameter for effective drainage.
Follow-up Care
- Confirm resolution with chest radiograph before tube removal
- Remove tube during expiration or Valsalva maneuver
- Apply occlusive dressing immediately after removal
- Obtain follow-up chest radiograph to confirm continued lung expansion 1