What are the indications for intercostal (between the ribs) tube drainage?

Indications for Intercostal Tube Drainage

Intercostal tube drainage is indicated for pneumothorax (when simple aspiration fails or in secondary pneumothorax with symptoms), hemothorax, pleural effusion requiring drainage, pleural empyema, and chylothorax. 1, 2, 3

Primary Indications

Pneumothorax

• Insert an intercostal tube if simple aspiration or catheter aspiration is unsuccessful in controlling symptoms. 1
• For secondary pneumothorax (underlying lung disease), intercostal tube drainage is recommended except in patients who are not breathless and have a very small (<1 cm or apical) pneumothorax. 1
• In primary pneumothorax, attempt simple aspiration first; if this fails (particularly if >2.5 L was aspirated during the unsuccessful attempt), proceed to tube drainage. 1
• Patients with chronic lung disease (cystic, fibrotic, bullous, or emphysematous) have less successful outcomes with simple drainage procedures and require closer observation. 1

Hemothorax

• Hemothorax requires chest tube drainage to evacuate blood from the pleural space. 2, 3
• Large-bore chest drains may be particularly useful for hemothorax due to the viscosity of blood. 3

Pleural Effusion

• Pleural effusions requiring therapeutic drainage are an indication for chest tube placement. 2, 3
• Small-bore chest tubes (≤14F) are generally recommended as first-line therapy for pleural effusions, with the possible exception of malignant effusions when immediate pleurodesis is planned. 3

Pleural Empyema

• Empyema (pus in the pleural space) requires chest tube drainage for source control and resolution. 2, 4
• For multiloculated collections resistant to simple drainage, consider intrapleural fibrinolytic therapy in addition to tube drainage. 5

Chylothorax

• Accumulation of lymphatic fluid (chyle) in the pleural space requires drainage via chest tube. 2, 6

Post-Operative/Post-Traumatic

• Major thoracic surgery routinely requires chest tube placement. 4
• Traumatic injuries to the chest with air or fluid accumulation necessitate tube drainage. 2

Clinical Decision-Making Algorithm

For Pneumothorax:

1. Assess if primary (no underlying lung disease) or secondary pneumothorax 1
2. Primary pneumothorax: Attempt simple aspiration first; if unsuccessful or patient remains symptomatic, insert chest tube 1
3. Secondary pneumothorax: Insert chest tube unless patient is not breathless AND pneumothorax is very small (<1 cm or apical only) 1
4. Significant dyspnea (obvious deterioration in usual exercise tolerance) requires intervention regardless of pneumothorax size 1

For Fluid Collections:

1. Determine nature of fluid: blood, pus, lymph, or serous effusion 2, 6
2. Image-guided placement is recommended (bedside ultrasound or CT) to optimize tube position 3
3. Small-bore tubes (≤14F) are first-line for most effusions 3
4. Consider large-bore tubes for hemothorax or very large air leaks 3

Critical Safety Considerations

Insertion Technique

• Never use a trocar or substantial force during insertion—this is the primary cause of catastrophic organ injury (lung, stomach, spleen, liver, heart, great vessels). 7, 2, 4
• Use blunt dissection for large tubes (>24F) or Seldinger technique for smaller tubes. 7, 3
• The optimal insertion site is the 4th, 5th, or 6th intercostal space in the mid- or anterior-axillary line. 2, 4

Post-Insertion Management

• A bubbling chest tube should never be clamped—this can convert a simple pneumothorax into life-threatening tension pneumothorax. 1, 7, 5
• Even non-bubbling tubes should not usually be clamped. 1, 7
• Use strict aseptic technique during insertion and manipulation to prevent empyema (occurs in 1-6% of cases). 7, 5

Tube Size Selection

• Small tubes (10-14F) are as effective as large tubes (20-24F) for pneumothorax management and should be used initially. 1, 3
• Consider larger tubes if there is a persistent large air leak, pleural fluid present, or if small tube fails. 1, 3
• Primary success rates of 84-97% have been recorded with small caliber tubes (7-9F). 1