What type and location of chest tube is recommended for placement in patients with pneumothorax or pleural effusion?

Chest Tube Selection and Placement for Pneumothorax and Pleural Effusion

For pneumothorax management, a 16F to 22F chest tube is recommended for most patients, while small-bore catheters (≤14F) are preferred for pleural effusions. 1

Pneumothorax Management

Tube Size Selection

• Large Pneumothorax:

  • Use 16F to 22F standard chest tubes for most clinically stable patients 1
  • For unstable patients or those requiring mechanical ventilation, use 24F to 28F chest tubes 1
  • Larger tubes (>28F) are generally not necessary 1

• Small Pneumothorax:

  • Small-bore catheters (≤14F) may be acceptable for small pneumothoraces in stable patients 1, 2
  • Observation alone may be appropriate for clinically stable patients with small pneumothoraces 1

Placement Location

• Position the tube at the apex of the thoracic cavity for pneumothorax 1
• For drainage systems, attach to either:
  • Water seal device with or without suction (preferred for most patients) 1
  • Heimlich valve (acceptable alternative, especially for outpatient management) 1

Pleural Effusion Management

Tube Size Selection

• Small-bore catheters (≤14F) are generally recommended as first-line therapy for most pleural effusions 2
• Exceptions where larger tubes may be needed:
  • Hemothorax (may benefit from larger tubes) 2, 3
  • Malignant effusions when immediate pleurodesis is planned 2

Placement Location

• Position the tube at the dependent portion of the effusion, typically the posterior basal area 1
• Image guidance (ultrasound or CT) should be used for placement 2

Special Considerations

Clinical Stability

• For unstable patients with pneumothorax of any size, chest tube placement is mandatory 1
• Unstable patients should be hospitalized with insertion of a chest tube to reexpand the lung 1

Technique Considerations

• Avoid the trocar technique due to risk of organ injury 2
• Use blunt dissection for tubes >24F or Seldinger technique for smaller tubes 2
• For ventilated patients, consider clamping the ventilator circuit before accessing the pleural space to prevent spreading of air or fluid 1

Drainage Systems

• Connect all chest tubes to an appropriate drainage system: 1, 2
  • Water seal device (with or without suction)
  • Electronic drainage systems
  • Heimlich valve (for selected cases)

Chest Tube Removal

• Remove tubes in a staged manner to ensure air leaks have resolved 1
• Discontinue suction and confirm resolution of pneumothorax on chest radiograph 1
• Chest tube clamping before removal is controversial and not universally recommended 2

Complications to Monitor

• Pain (more common with larger tubes) 1, 3
• Tube blockage (more common with small-bore tubes) 1, 2
• Accidental dislodgment 2
• More serious complications: organ injury, hemothorax, infection, re-expansion pulmonary edema 2

Recent evidence suggests that small-bore catheters (14F) can be as effective as larger chest tubes (28-32F) even for traumatic hemothorax, with patients reporting better insertion experience scores with smaller tubes 3.