Can a chest tube be removed in the presence of underlying lung collapse?

Chest Tube Removal with Underlying Lung Collapse

Chest tubes should not be removed in the presence of underlying lung collapse as this could lead to increased morbidity and mortality, unless specific criteria are met. 1, 2

Decision Algorithm for Chest Tube Removal

Absolute Contraindications to Removal:

• Active air leak with expanding pneumothorax
• Bubbling chest tube (never clamp these tubes as this can convert a simple pneumothorax to a life-threatening tension pneumothorax) 2
• Incomplete lung expansion with ongoing clinical symptoms

Conditional Removal Criteria:

The American College of Chest Physicians guidelines suggest chest tube removal may be considered despite underlying collapse if:

1. The patient has been clinically stable and asymptomatic for at least 14 days
2. No subcutaneous emphysema is present
3. The pleural space deficit (pneumothorax) has not increased in size
4. The patient has completed a trial period without suction 1, 2

Chest Tube Removal Protocol

Pre-Removal Assessment:

• Confirm pneumothorax is stable or improving on chest radiograph
• Ensure no clinical evidence of ongoing air leak
• Discontinue any suction and observe on water seal before removal 2

Monitoring Period:

• After discontinuing suction, observe the patient for 5-12 hours (62% of experts recommend this timeframe) 1
• Repeat chest radiograph during this period to confirm stability

Removal Technique:

• Provide adequate analgesia before chest tube removal
• Remove the tube during expiration or Valsalva maneuver
• Apply an occlusive dressing immediately after removal 2

Special Considerations

Persistent Air Leaks:

For patients with persistent air leaks who have been managed conservatively:

• Consider removal if the patient has been stable for at least 14 days on a portable drainage device
• Even with a non-expanding pneumothorax, removal may be safe if the patient is asymptomatic and the pneumothorax size has been stable 3

Post-Removal Monitoring:

• Obtain a chest radiograph after removal to assess for pneumothorax development or expansion
• Monitor for signs of respiratory distress, which may indicate tension pneumothorax development

Pitfalls and Caveats

1. Never clamp a bubbling chest tube - this can lead to tension pneumothorax, which is life-threatening 2

2. Avoid premature removal - removing chest tubes too early can lead to increased hospital complications and costs 4

3. Consider outpatient management - For persistent air leaks, patients can be safely discharged home with chest tubes connected to portable drainage devices, with planned removal after 2-3 weeks even if a small air leak persists 5

4. Recognize high-risk scenarios - Complete lung collapse with mediastinal shift represents a medical emergency requiring immediate intervention, not chest tube removal 6

The most recent guidelines emphasize that chest tube removal decisions should be based on both radiographic evidence of lung re-expansion and clinical assessment of air leak resolution, with the primary goal of preventing recurrent pneumothorax and ensuring patient safety 2.