What is the standard care and management after chest tube removal?

Standard Care and Management After Chest Tube Removal

Chest tubes should be removed when there is clinical resolution, with proper analgesia, during expiration or Valsalva maneuver, followed by an occlusive dressing and a post-removal chest radiograph to ensure no pneumothorax has developed. 1

Criteria for Chest Tube Removal

• Chest tubes should be removed when there is complete resolution of the pneumothorax on chest radiograph and no clinical evidence of an ongoing air leak 1
• Any suction applied to the chest tube should be discontinued before considering removal 1
• For mediastinal drains after cardiac surgery, they can be safely removed as soon as the drainage becomes macroscopically serous 1
• In children with pleural infection, the timing of removal depends on clinical factors including amount of fluid draining, temperature, general well-being, radiographic appearance, and fall in acute phase reactants 1
• It is not necessary to wait for complete cessation of drainage before removing a chest tube 1

Removal Procedure

• Adequate analgesia should be provided before chest tube removal 1

  • Local anesthetic cream applied to the adjacent skin 3 hours before removal has been shown to be as effective as intravenous morphine for pain control in children 1
  • Sedation may be necessary in young children 1

• The chest tube should be removed using proper technique:

  • Remove the tube either while the patient performs Valsalva's maneuver or during expiration 1
  • Use a brisk firm movement for removal 1
  • For surgically placed drains with a closure suture, the suture should be approximated while the drain is being removed 1
  • The procedure should be performed by properly trained nursing or medical staff 1

Post-Removal Management

• A chest radiograph should be taken shortly after chest tube removal to ensure a pneumothorax has not developed 1

  • Most experts recommend obtaining this radiograph within 5-12 hours after removal 1

• The exit wound should be managed appropriately:

  • For smaller drains, surgical closure is not necessary 1
  • An occlusive dressing should be applied at the site of chest tube removal 2
  • Cyanoacrylate tissue adhesive (Dermabond®) has been shown to be an effective and safe alternative to standard gauze dressings for closure of chest tube drain sites in children 2

• Monitor for potential complications:

  • Watch for signs of pneumothorax, which may require chest tube reinsertion 1
  • Be alert for delayed pleural effusions, especially after early chest tube removal 1, 3

Special Considerations

• Early chest tube removal (even on postoperative day 0) may be safe in selected patients after thoracoscopic procedures when using digital drainage device protocols 3

  • Criteria for early removal include air flow ≤20 ml/min for at least 4 hours without significant fluid drainage 3
  • Early removal is associated with shorter hospital stays and reduced pain medication requirements 3, 4

• For patients with persistent air leaks (beyond 4 days), surgical evaluation should be considered 1, 5

• After cardiac surgery, early chest tube removal by properly trained nurses can facilitate earlier and more aggressive ambulation, potentially decreasing length of stay 6

• Patients with chest tubes should be managed on specialized wards by staff trained in chest tube management to ensure optimal care and minimize risks 5

Potential Complications and Their Management

• Pneumothorax: If detected on post-removal chest radiograph, may require reinsertion of a chest tube depending on size and symptoms 1
• Pleural effusion: May develop after early chest tube removal and require drainage if symptomatic 1, 3
• Wound infection: Rare but should be monitored; proper sterile technique during removal helps prevent this complication 2