Protocol for Chest Tube Removal After Pneumothorax
The protocol for removing a chest tube after pneumothorax requires confirming lung re-expansion, absence of air leak for at least 24 hours, and removal during full inspiration while the patient holds their breath. 1
Pre-removal Assessment
- Ensure complete lung re-expansion on chest radiograph before considering chest tube removal 1, 2
- Verify absence of bubbling in the underwater seal collection system for at least 24 hours, which confirms resolution of air leak 2
- Check that drainage is minimal (less than 150 mL in 24 hours) 3
- Assess that the patient is clinically stable with no respiratory distress 4
Preparation for Removal
- Explain the procedure to the patient and provide reassurance throughout 1
- Consider premedication with atropine to prevent vasovagal reactions 1
- For anxious patients, a small dose of intravenous midazolam may be administered 1
- Prescribe adequate analgesia (both oral and intramuscular) before the procedure 1
Removal Technique
- Remove the suture that holds the drain in place 1
- Instruct the patient to hold their breath in full inspiration 1, 5
- Withdraw the tube quickly and smoothly during this breath-hold 1
- Immediately seal the wound using the two remaining sutures 1
Note: Research shows that removal at end-inspiration or end-expiration has similar safety profiles with no significant difference in post-removal pneumothorax rates 5
Post-removal Monitoring
- Obtain a chest radiograph within 1-3 hours after chest tube removal to check for recurrent pneumothorax 3
- All significant pneumothoraces that require intervention will be visible on this initial post-removal radiograph 3
- Monitor vital signs including respiratory rate, heart rate, blood pressure, and oxygen saturation 4
- Observe for signs of respiratory distress or subcutaneous emphysema 2, 4
Special Considerations
- Never clamp a bubbling chest tube as this may lead to tension pneumothorax, a potentially fatal complication 2
- Patients with chronic lung disease (cystic, fibrotic, bullous, or emphysematous) require closer monitoring as drainage procedures are less successful 1
- In mechanically ventilated patients, use larger bore chest tubes (24F-28F) and ensure complete resolution of air leak before removal 4
Discharge Planning
- Provide the patient with a discharge letter and clear instructions to return immediately if they experience deterioration 1
- Arrange for a chest clinic follow-up appointment in 7-10 days 1
- Advise patients to avoid air travel until radiographic changes have completely resolved 1
Management of Complications
- If a recurrent pneumothorax develops after tube removal (occurs in approximately 6-12% of cases), reassess the need for reinsertion based on size and symptoms 6, 5
- For persistent air leaks (beyond 4 days), consider referral for specialist respiratory evaluation and possible surgical intervention 2, 4
- Small, stable pneumothoraces without clinical symptoms may be managed conservatively without reinsertion of a chest tube 6