What are the indications for chest tube (chest drainage tube) placement?

Indications for Chest Tube Placement

Chest tubes should be placed for pneumothorax (large or symptomatic), hemothorax, pleural empyema, complicated parapneumonic effusions with pleural pH <7.2, and large symptomatic pleural effusions causing respiratory compromise. 1

Primary Indications

Pleural Infection and Empyema

• Frank pus (empyema) always requires immediate chest tube drainage, regardless of other factors 1
• Pleural fluid pH <7.2 predicts the need for drainage and should trigger immediate chest tube placement 1
• Loculated pleural collections require earlier chest tube drainage due to association with poorer outcomes 1
• Large pleural collections (>40% of hemithorax) are more likely to require surgical intervention and warrant chest tube placement 1
• Delay in chest tube drainage is associated with increased morbidity, prolonged hospital stay, and potentially increased mortality 1

Pneumothorax

• Large pneumothoraces always require chest tube placement regardless of clinical stability 1
• Small pneumothoraces require chest tube placement only if the patient is clinically unstable 1
• Clinically stable patients with small pneumothoraces may be observed closely in the outpatient setting 1, 2
• Spontaneous primary pneumothorax can be managed outpatient with needle aspiration if the patient is minimally symptomatic and risk assessment allows 2

Parapneumonic Effusions (Adults)

The decision algorithm is based on effusion size and characteristics:

Small effusions (<10mm rim):

• Do not drain; treat with antibiotics alone 2

Moderate effusions (>10mm but <50% hemithorax):

• If bacterial culture/Gram stain negative AND low respiratory compromise: treat with IV antibiotics alone 2
• If respiratory distress present OR empyema documented: drain immediately 2

Large effusions (>50% hemithorax):

• Drain in most cases, especially with respiratory compromise 2

Parapneumonic Effusions (Pediatric)

• Small, uncomplicated parapneumonic effusions should NOT be routinely drained and can be treated with antibiotics alone 1, 2
• Moderate effusions with respiratory distress, large effusions, or documented purulent effusions require drainage 1, 2
• Loculated effusions cannot be drained with chest tube alone and require adjunctive therapy (fibrinolysis or VATS) 1

Hemothorax

• Chest tube placement is indicated for hemothorax to drain blood and allow lung re-expansion 3, 4, 5

Large Symptomatic Effusions

• Non-purulent effusions without acidosis should be drained by chest tube for symptomatic benefit when they are large and causing respiratory compromise 1
• On suspicion of malignant effusion, diagnostic pleural fluid aspiration should be performed, especially if the patient is a candidate for systemic therapy or if the effusion is symptomatic 2

Post-Surgical Prophylaxis

• Chest tubes are routinely placed after major thoracic surgery for prophylactic drainage of air, blood, and other fluids 6

Critical Management Principles

Specialist Involvement

• A respiratory physician or thoracic surgeon should be involved in all cases requiring chest tube drainage for pleural infection 1

Common Pitfalls to Avoid

• Never use trocars for chest tube insertion due to high risk of intrathoracic organ damage, hemothorax, and lung lacerations 1, 3, 4
• Misdiagnosis, inappropriate antibiotics, and inappropriate tube placement contribute to progression of pleural infection 1
• Delay in drainage significantly worsens outcomes 1

Technical Considerations

• Small-bore chest tubes (10-14F) should be used initially for most pneumothoraces, with larger tubes only considered when there is persistent air leak or pleural fluid present 7
• Extra care must be taken when placing chest tubes to avoid open communication with the pleural space and potential emission of droplets and aerosols 7, 2
• The most appropriate site for chest tube placement is the 4th or 5th intercostal space in the mid- or anterior-axillary line 3, 4