What amount of chest tube output is considered excessive?

Chest Tube Output Thresholds: Evidence-Based Guidelines

Chest tube drainage of up to 450 mL/day is considered safe for removal in most clinical scenarios, with higher thresholds (up to 500 mL/day) being acceptable for post-lung resection patients specifically. 1, 2, 3

General Principles for Chest Tube Management

• Traditional thresholds for chest tube removal (250 mL/day) are based on expert opinion rather than strong evidence, with recent studies supporting higher acceptable drainage volumes 1
• Higher drainage thresholds (450 mL/day versus traditional 250 mL/day) for chest tube removal post-lung resection have been associated with improved respiratory function, reduced infection rates, decreased pain, and earlier tube removal 1
• Early chest tube removal with higher drainage thresholds has been shown to reduce hospital length of stay without increasing readmission rates or complications 1, 2

Evidence-Based Thresholds by Clinical Scenario

Post-Lung Resection

• Chest tubes can be safely removed with drainage up to 450-500 mL/day of non-chylous fluid 1, 2, 3
• Studies show readmission rates due to recurrent symptomatic effusions are extremely low (0.55-2.8%) when using these higher thresholds 2, 3
• The practice of keeping chest tubes in place for drainage less than 450 mL/day after pulmonary resection is not supported by evidence 2

Post-Cardiac Surgery

• Higher thresholds (up to 450 mL/day) for chest tube removal are also applicable to cardiac surgery patients 1
• Some centers have demonstrated that chest tube output volume before removal can be safely increased to 8.5 mL/kg/24h (versus traditional 2.2 mL/kg/24h) without increasing rates of chest tube reinsertion or readmission 1

Special Considerations

• For patients requiring mechanical ventilation or those who are clinically unstable, lower thresholds may be appropriate as they are at higher risk for large pleural air leaks 1
• The quality of drainage (serous vs. bloody or chylous) should be considered alongside volume when making removal decisions 1

Potential Time-Saving Approaches

• Pleural fluid output measured at 6,8, or 12 hours can accurately predict which patients will meet 24-hour fluid output thresholds for safe chest tube removal 4
• This approach can potentially save 10-16 hours in drainage duration without compromising safety 4

Common Pitfalls and Caveats

• Focusing solely on drainage volume without considering other clinical factors (air leak, fluid quality, patient stability) may lead to premature chest tube removal 1
• Chest tubes should not be removed if there is evidence of ongoing air leak, regardless of fluid output volume 1, 5
• Early chest tube removal after thoracic surgery may be associated with an increased risk of pleural effusions requiring intervention in some studies, highlighting the need for careful patient selection 1
• Patients who have undergone thoracic surgery should avoid air travel until intrathoracic gas resorption is completed (typically 3-10 days after surgery) 1

Technological Considerations

• Active tube clearance systems may help prevent chest tube occlusion and allow for more accurate assessment of true drainage volumes 1, 6
• Digital drainage systems provide more accurate and consistent measurement of chest tube output compared to traditional analog systems 1

By implementing these evidence-based thresholds for chest tube removal, clinicians can potentially reduce hospital length of stay, decrease patient discomfort, and improve resource utilization without compromising patient safety.