Chest Tube Management for Pleural Space Drainage
Small-bore chest tubes (14F or smaller) should be used as the initial drainage strategy for pleural infection and effusions, as they are equally effective as large-bore tubes while causing less pain and discomfort. 1
Indications for Chest Tube Insertion
- Frank pus (empyema): Requires immediate drainage
- Pleural fluid pH <7.2 in suspected pleural infection
- Turbid/cloudy pleural fluid on sampling
- Positive Gram stain or culture from non-purulent pleural fluid
- Large effusions (>40% of hemithorax)
- Symptomatic effusions causing dyspnea or respiratory compromise
- Loculated collections should receive earlier drainage
Chest Tube Selection and Insertion
Tube Size
Small-bore tubes (≤14F) are recommended as first-line for:
- Pleural effusions (including infected effusions)
- Spontaneous pneumothorax in non-ventilated patients
- Malignant effusions (unless immediate pleurodesis is planned)
Large-bore tubes may be considered for:
- Very large air leaks
- Hemothorax
- After ineffective trial with small-bore drains
Insertion Technique
- Image guidance is essential - ultrasound or CT should guide placement 1
- Avoid trocar technique - associated with higher complication rates 2
- Preferred methods:
- Seldinger technique for small-bore tubes
- Blunt dissection for tubes >24F
- Optimal insertion site: 4th or 5th intercostal space in mid- or anterior-axillary line 3
- Safe triangle: Area bordered by anterior border of latissimus dorsi, lateral border of pectoralis major, and line horizontal to nipple
Chest Tube Management
Initial Management
- Connect to a unidirectional flow drainage system (underwater seal bottle) 1
- Keep drainage system below patient's chest level at all times
- Apply suction only if necessary (not routinely recommended)
- Initial drainage should not exceed 1.5L at once to prevent re-expansion pulmonary edema 4
- If draining large effusions, clamp drain for 1 hour after initial 10 ml/kg removal 1
Ongoing Management
- Never clamp a bubbling chest tube 1
- Immediately unclamp if patient develops breathlessness or chest pain
- Maintain on specialist wards with trained staff
- Check for obstruction (blockage or kinking) by flushing if drainage suddenly stops
- Chest radiograph should be performed after insertion to confirm position
Drainage Assessment
- Maintain suction at 20 cm H₂O when indicated
- Remove chest tube when:
- Clinical resolution is achieved
- 24-hour drainage is 100-150 ml or less 1
- No air leak is present
- Radiographic improvement is seen
Special Considerations for Pleural Infection
Antibiotics
- All patients should receive appropriate antibiotics 1
- Guide antibiotic choice by culture results when available
- For culture-negative community-acquired infection:
- Cefuroxime + metronidazole OR
- Benzyl penicillin + ciprofloxacin OR
- Amoxicillin-clavulanic acid
- For hospital-acquired infection, broader spectrum coverage is required
Intrapleural Fibrinolytics
- Consider for complicated parapneumonic effusions or empyema with loculations 1
- Options include:
Surgical Referral
- Consider early discussion with thoracic surgeon if:
- Failure of chest tube drainage, antibiotics, and fibrinolytics
- Persistent sepsis despite adequate drainage
- Multiloculated effusions not responding to medical therapy
- Trapped lung preventing re-expansion
Complications to Monitor
- Pain (more common with large-bore tubes)
- Drain blockage or dislodgment
- Infection at insertion site
- Organ injury
- Hemothorax
- Re-expansion pulmonary edema
- Subcutaneous emphysema
Special Populations
Malignant Pleural Effusions
- Consider indwelling pleural catheters (IPC) as first-line palliative therapy for recurrent malignant effusions 2
- For definitive management, talc pleurodesis (either slurry or poudrage) is effective 1
- Talc slurry: 4-5g in 50ml normal saline, clamp for 1 hour, then maintain suction
By following these evidence-based guidelines for chest tube management, clinicians can optimize drainage while minimizing complications and improving patient outcomes.