What are the indications for InterCostal Thoracic Drainage (ICTD) or chest tube removal?

Indications for Chest Tube Removal

A chest tube should be removed when there is absence of an intrathoracic air leak and when pleural fluid drainage is less than 250 ml/day, with complete lung re-expansion confirmed on chest radiograph. 1

Primary Criteria for Chest Tube Removal

The decision to remove a chest tube should be based on the following criteria:

For Pneumothorax

• Complete lung re-expansion confirmed on chest radiograph
• Absence of air leak
• For pediatric patients: drainage <1 ml/kg/24h (usually calculated over the last 12 hours) 2
• For adult patients: drainage <250 ml/day 1

For Pleural Effusion/Fluid Drainage

• Adequate drainage with minimal residual fluid
• Drainage volume <250 ml/day 1
• Some studies suggest that a threshold of 200 ml/day is safe and does not increase the risk of fluid reaccumulation compared to more conservative thresholds like 100 ml/day 3

Protocol for Chest Tube Removal

1. Discontinue suction first

   • Observe for 4-24 hours without suction to ensure stability 1
   • Confirm no air leak during this observation period

2. Confirm resolution criteria

   • Obtain chest radiograph 5-12 hours after last evidence of air leak
   • Verify complete lung expansion
   • Ensure drainage is below threshold (250 ml/day or <1 ml/kg/24h for pediatrics)

3. Patient preparation

   • Consider premedication with atropine to prevent vasovagal reaction
   • Provide adequate analgesia
   • Position patient appropriately 1

4. Removal technique

   • Remove suture securing the tube
   • Have patient hold breath at end-expiration
   • Withdraw tube quickly and immediately seal wound with remaining sutures 1

5. Post-removal monitoring

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

Special Considerations

Timing of Removal

• For pediatric patients after primary drainage or VATS, chest tube removal can often be accomplished within 48-72 hours after the operation or completion of fibrinolysis 2
• For post-pleurodesis cases, a period of 12-72 hours after sclerosant administration with minimal drainage is recommended 1

Removal Despite Air Leak

• In select cases, chest tubes can be safely removed even with a persistent air leak if:
  • The patient has been asymptomatic
  • No subcutaneous emphysema after approximately 14 days on a portable device
  • The pleural space deficit has not increased in size 4
  • However, this approach should be used cautiously and is not standard practice

Common Pitfalls to Avoid

1. Premature removal - Removing chest tube before adequate drainage or resolution of air leak can lead to reaccumulation or pneumothorax
2. Unnecessary prolonged drainage - Keeping chest tubes longer than necessary increases infection risk and patient discomfort
3. Improper clamping - Clamping chest tubes is generally not recommended as it can lead to tension pneumothorax
4. Inadequate post-removal monitoring - Failure to obtain post-removal imaging or monitor for complications

By following these evidence-based guidelines for chest tube removal, clinicians can optimize patient outcomes while minimizing complications and length of hospital stay.