What size chest tube is recommended for my patient?

Chest Tube Size Selection

For most clinical situations, start with a small-bore chest tube (14F or smaller), as this provides equivalent efficacy to larger tubes with fewer complications and less pain. 1, 2

Primary Recommendation by Clinical Indication

Pleural Infection/Empyema

• Use 14F or smaller chest tubes as initial drainage strategy 1
• The 2023 British Thoracic Society guidelines explicitly state that chest tube bore size has no effect on mortality, need for post-treatment surgery, or length of hospital stay, though tubes >14F may increase post-treatment pain 1
• Small-bore tubes allow for chemical pleurodesis if needed 1

Spontaneous Pneumothorax

• Initial management should use 10-14F chest tubes 1, 2
• Success rates of 84-97% have been documented with tubes as small as 7-9F 1, 2
• There is no evidence that large tubes (20-24F) provide better outcomes than small tubes (10-14F) 1, 2
• Median drainage duration with small-caliber systems is 2-4 days, comparable to larger systems 1

Traumatic Hemothorax/Pneumothorax

• Small-bore tubes (≤20F) are effective and safe for most trauma patients 3, 4
• A prospective trauma study found no difference in retained hemothorax (11.8% vs 10.7%), empyema (4.2% vs 4.6%), or need for additional procedures when comparing 28-32F versus 36-40F tubes 5
• Tube size did not affect pain scores in trauma patients (6.0 vs 6.7 on visual analog scale, p=0.237) 5

When to Consider Larger Tubes (>14F)

Upgrade to larger bore tubes only in these specific situations:

• Mechanically ventilated patients with pneumothorax - the positive pressure ventilation creates larger air leaks that may exceed small tube capacity 6
• Massive ongoing air leak that causes persistent bubbling and prevents lung re-expansion with a small tube 1
• Viscous pleural fluid such as clotted hemothorax that cannot drain through smaller caliber 6
• Failure of initial small tube - if pneumothorax/hemothorax persists after 48 hours with adequate tube positioning 1

Critical Pitfalls to Avoid

• Never assume larger is better - the evidence consistently shows no benefit to routine use of large-bore tubes (20-24F or 28-40F) for initial management 1, 5
• Don't clamp a bubbling chest tube - this can convert a simple pneumothorax into tension pneumothorax 1
• Maintain strict aseptic technique - empyema rates of 1-6% are reported with chest tube insertion 1
• Watch for tube malposition or kinking - these can cause surgical emphysema and treatment failure, not inadequate tube size 1

Evidence Quality Assessment

The 2023 British Thoracic Society guideline 1 represents the most recent and authoritative source, providing a conditional recommendation for ≤14F tubes in pleural infection based on evidence showing no mortality or efficacy differences but potential pain reduction. The 2003 BTS pneumothorax guidelines 1 remain relevant as no higher-quality evidence has superseded these recommendations. Multiple trauma studies from 2012-2020 3, 4, 5, 7 consistently support small-bore tube efficacy even in the high-risk trauma population, with one prospective study of 353 tubes finding no clinically relevant outcome differences 5.