Should tip eyelets of a chest tube be removed in a thin patient?

Chest Tube Tip Eyelet Removal in Thin Patients

Do not remove tip eyelets from chest tubes in thin patients—all drainage holes should remain within the pleural cavity regardless of patient body habitus.

Rationale for Keeping All Eyelets Intrathoracic

The fundamental principle of chest tube placement is ensuring all drainage holes (eyelets) reside within the pleural space to prevent subcutaneous emphysema and maintain effective drainage 1. While thin patients present anatomical challenges due to reduced chest wall thickness, this does not justify removing drainage holes from the tube itself.

Proper Tube Selection and Placement Strategy

For thin patients, the solution is appropriate tube selection and careful insertion technique, not eyelet removal:

• Small-bore tubes (10-14F) are recommended as initial treatment for pneumothoraces and are particularly suitable for thin patients due to their shorter length and fewer drainage holes 1
• Larger tubes (24F-28F) should be reserved for unstable patients, those requiring mechanical ventilation, or situations with large air leaks that exceed smaller tube capacity 1, 2
• The key is ensuring the most proximal (closest to skin) eyelet sits just inside the pleural cavity, which requires careful measurement and insertion depth control 3

Why Eyelet Position Matters More Than Location

Chest tube location within the pleural space does not significantly influence outcomes—what matters is that the tube resides in the pleural cavity with all holes intrathoracic:

• A trauma study of 291 patients found that neither high versus low rib space placement nor tube location relative to lung parenchyma affected the need for secondary interventions 4
• The severity of underlying pathology (chest AIS scores, hemothorax volume) was the only significant predictor of outcomes, not tube positioning 4
• Traditional teaching about directing tubes anterosuperiorly for pneumothorax or posteroinferiorly for hemothorax lacks evidence-based support 4

Technical Approach for Thin Patients

Use imaging guidance and blunt dissection technique:

• Chest tube insertion should be guided by bedside ultrasonography or CT to ensure proper depth 3
• The trocar technique must be avoided; instead use blunt dissection (for tubes >24F) or Seldinger technique 3
• Measure the required insertion depth based on chest wall thickness visible on imaging before insertion 3

Common Pitfalls to Avoid

The most critical error is having any eyelet outside the pleural cavity:

• If the most proximal eyelet sits in the subcutaneous tissue, air or fluid will track into soft tissues rather than draining effectively 3
• This creates subcutaneous emphysema and defeats the purpose of tube placement 3
• In thin patients, this risk is higher due to reduced chest wall thickness, but the solution is selecting a shorter tube or limiting insertion depth, not removing eyelets 1, 3

Never clamp a bubbling chest tube as this may cause tension pneumothorax 5

Monitoring and Troubleshooting

• Visual assessment of air bubbling in the underwater seal confirms proper tube function and ongoing air leak 5
• Respiratory swing of fluid confirms tube patency and proper pleural positioning 5
• If drainage suddenly ceases, check for kinking (especially with small-bore tubes in mobile patients) and flush with normal saline if obstruction is suspected 5