Management of Slowed Chest Tube Output
When chest tube output slows or stops, immediately assess for tube malfunction by checking patency through flushing with 20-50ml normal saline and obtain imaging to evaluate tube position—do not simply observe or rely on antibiotics alone. 1
Initial Assessment Algorithm
Step 1: Verify Tube Patency and Position
- Flush the chest tube with 20-50ml of normal saline to confirm patency and rule out obstruction from clot or fibrin 1
- Perform immediate imaging—chest X-ray as first-line, but contrast-enhanced CT is the most useful modality for patients with persistent drainage failure 1
- Check for tube kinking, malposition, or displacement into subcutaneous tissue 2, 3
Step 2: Identify the Underlying Problem
Common causes of slowed output include:
- Tube obstruction from clot or debris (most common in post-surgical or hemothorax cases) 2, 3
- Tube kinking or malposition 2, 3, 4
- Loculated fluid collections that the current tube cannot reach 1
- Loose connections or inadequate drainage system setup 3
- Resolution of the underlying condition (pneumothorax sealed, effusion drained)
Management Based on Findings
If Tube is Obstructed but Well-Positioned
- Placement of a second chest tube is the most effective intervention to prevent complications like empyema, particularly in hemothorax cases 1
- Consider intrapleural fibrinolytic therapy (streptokinase 250,000 IU twice daily for 3 days or urokinase 100,000 IU once daily for 3 days) for loculated collections 1
- Do NOT routinely strip or milk chest tubes, as this can cause tissue trauma, hemorrhage, and disruption of structures due to high negative pressure 2
- Never break the sterile field to manually clear obstructions, as this significantly increases infection risk 2
If Tube is Kinked or Malpositioned
- Reposition or replace the tube under imaging guidance 1
- Small-bore tubes (≤14F) have success rates of 84-97% but may require replacement with larger tubes (16-22F) if there is a large air leak or significant pleural fluid 2, 5
If Persistent Air Leak After 48 Hours
- Refer to a respiratory physician or thoracic surgeon for complex drain management 2
- Consider adding high-volume, low-pressure suction (-10 to -20 cm H₂O) after 48 hours if the lung fails to re-expand 2
- Suction should NOT be applied immediately after tube insertion but reserved for persistent problems 2
Critical Safety Points
Never Clamp a Chest Tube That Is Bubbling
- A bubbling chest tube should NEVER be clamped, as this can convert a simple pneumothorax into life-threatening tension pneumothorax 2, 1
- Even non-bubbling tubes should generally not be clamped 2
- If clamping is absolutely necessary (under specialist supervision only), the patient must remain in a monitored ward setting and never leave the ward 2
Timing for Specialist Referral
- Any pneumothorax or effusion failing to respond within 48 hours requires specialist referral 2
- Persistent air leak beyond 48 hours mandates respiratory physician involvement 2
- These patients require specialized nursing care experienced in complex drain management 2
Role of Antibiotics
Do NOT rely on antibiotics as the primary intervention for slowed chest tube output with residual fluid collections 1. The problem is mechanical, not primarily infectious. Antibiotics show benefit mainly in penetrating thoracic injuries, not in managing tube dysfunction or retained collections 1.
Common Pitfalls to Avoid
- Assuming the tube is functioning based on chest X-ray alone—up to 55% of malpositioned tubes are missed on supine AP chest radiographs 6
- Waiting too long before obtaining CT imaging when drainage is inadequate 1
- Using antibiotics alone without addressing mechanical drainage problems 1
- Attempting aggressive manual manipulation (stripping/milking) which can cause complications 2
- Failing to recognize that median time to resolution can be 8 days (19 days with underlying lung disease), so some patience is warranted if the tube is functioning properly 2