Chest Tube Management: Wet vs. Dry Suction Guidelines
The American College of Chest Physicians recommends starting chest tube management with water seal alone (without suction) as the first-line approach, connecting the tube to a unidirectional flow drainage system and only applying suction (5-10 cm H₂O) when the lung fails to re-expand quickly or for large pneumothoraces with significant air leaks. 1
Initial Chest Tube Setup
Water Seal vs. Suction
- Start with water seal alone (no suction) for most cases 1
- Maintain the drainage system below the level of the patient's chest at all times 1
- Connect to a unidirectional flow drainage system 1
When to Apply Suction
Apply suction (5-10 cm H₂O) only when:
- The lung fails to re-expand quickly with water seal alone
- For large pneumothoraces with significant air leaks
- When patients require positive-pressure ventilation 1
Types of Chest Drainage Systems
Wet Suction Systems
- Traditional system using water columns
- Requires water in both the collection chamber and suction control chamber
- Visual indicator of suction level (bubbling in suction control chamber)
- Disadvantages: bulky, risk of spillage, difficult to transport 1
Dry Suction Systems
- Modern alternative using mechanical regulators instead of water columns
- More precise suction control
- Quieter operation with less bubbling
- Easier to transport
- Important: While these systems provide predictable suction at the device, actual intrapleural pressures can vary significantly depending on tube patency 2
Evidence-Based Management Practices
Tube Size Selection
- 24F to 28F: For large pneumothoraces or bronchopleural fistulas
- 16F to 22F: For most standard cases
- ≤14F (small-bore catheters): For stable patients with smaller pneumothoraces 1
Monitoring and Maintenance
- Monitor for lung re-expansion and resolution of pneumothorax
- Check for proper drainage function regularly
- Ensure connecting tubes remain patent - obstructions can significantly alter intrapleural pressures 2
- Never clamp a bubbling chest tube (can convert simple pneumothorax to tension pneumothorax) 1
Suction Level Considerations
- Standard suction level: 5-10 cm H₂O when indicated 1
- Higher levels of suction have not been shown to improve outcomes and may prolong air leaks 3
- Digital drainage systems can reduce interobserver variability in air leak assessment and may shorten chest tube duration 3
Clinical Context Considerations
Post-Cardiac Surgery
- Traditional practice has been -20 cm H₂O wall suction until removal
- Evidence suggests changing to water seal after 12 hours of wall suction is a safe alternative with no difference in complications, chest tube output, or duration of placement 4
Traumatic Chest Injury
- Suction appears to have advantages over water seal for:
- Shorter duration of chest tube treatment
- Shorter hospital length of stay
- Lower incidence of persistent air leak 5
Critical Complications to Avoid
Tension Pneumothorax
- Can develop if a chest tube is clamped or if there's inadequate drainage
- Life-threatening emergency with signs including respiratory distress, tachycardia, hypotension
- Immediate unclamping or decompression is required 1
Other Complications
- Subcutaneous emphysema
- Infection (approximately 1% of cases)
- Pain, drain blockage, accidental dislodgment
- Organ injury, hemothorax, re-expansion pulmonary edema (approximately 11% of cases) 1
Chest Tube Removal
- Confirm pneumothorax resolution by chest radiograph
- Ensure no clinical evidence of ongoing air leak
- Remove during expiration or Valsalva maneuver
- Apply occlusive dressing immediately after removal
- Obtain follow-up chest radiograph to confirm continued lung expansion 1
Emerging Technology
Digital suction devices can identify air leak resolution and may eventually guide suction minimization through real-time monitoring of pleural apposition, potentially allowing for automated adjustment to the minimum required suction level 6