Chest Tube Recommendations for Pneumothorax Based on Size
Chest tube placement is recommended for large pneumothoraces (>2 cm or >20% of hemithorax on chest X-ray or >35 mm on CT scan) and for small pneumothoraces in clinically unstable patients. 1, 2, 3
Primary Pneumothorax Management
- For primary pneumothoraces, simple aspiration should be attempted first if the pneumothorax is <2 cm and the patient is clinically stable 1
- Large primary pneumothoraces (>2 cm) should be managed with chest tube drainage if simple aspiration fails 1
- Small primary pneumothoraces (<1 cm or apical) in stable, non-breathless patients can be observed without chest tube placement 1
- Repeat aspiration is reasonable when first aspiration is unsuccessful and <2.5 L has been aspirated on the first attempt 1
Secondary Pneumothorax Management
- Intercostal tube drainage is recommended for secondary pneumothoraces except in patients who are not breathless and have a very small (<1 cm or apical) pneumothorax 1
- Large secondary pneumothoraces (>2 cm), particularly in patients over 50 years old, have a high risk of failure with simple aspiration and should be treated with tube drainage as initial treatment 1
- Patients with secondary pneumothoraces who undergo simple aspiration should be admitted for observation for at least 24 hours 1
Chest Tube Size Selection
- Small-bore tubes (10-14F) are recommended as initial treatment for pneumothoraces 1, 2
- There is no evidence that large tubes (20-24F) are better than small tubes (10-14F) in managing pneumothoraces 1, 4
- For unstable patients or those requiring mechanical ventilation with large pneumothorax, larger tubes (24F-28F) may be appropriate 2, 5
- Factors that might favor larger tube selection include presence of pleural fluid and large air leaks that exceed the capacity of smaller tubes 1
Special Considerations
- Pneumothoraces that fail to respond within 48 hours to treatment should be referred to a respiratory physician 1
- For patients with cystic fibrosis, chest tube placement is recommended for large pneumothoraces regardless of clinical stability 1
- For patients with cystic fibrosis with small pneumothoraces, chest tube placement is only recommended if there is clinical instability 1
- Pleurodesis should not be performed for first pneumothorax but should be considered for recurrent large pneumothoraces 1
Complications and Pitfalls
- Pain is more common with larger tubes, which is why smaller tubes are preferred when possible 2, 4
- Tube blockage is more common with small-bore tubes, which may necessitate replacement with a larger tube if there is a persistent air leak 1, 2
- Chest tube insertion should be guided by imaging (ultrasound or CT) to avoid complications 4
- The trocar technique should be avoided due to risk of organ injury; instead, use blunt dissection for larger tubes or the Seldinger technique for smaller tubes 4, 6