When is insertion of a chest drain recommended?

When to Insert a Chest Drain

Insert a chest drain for pneumothorax requiring intervention, pleural infection (confirmed or suspected empyema), hemothorax, massive effusions causing severe respiratory compromise, or enlarging parapneumonic effusions that cannot be managed with antibiotics alone. 1

Primary Indications for Chest Drain Insertion

Pneumothorax

• Spontaneous primary pneumothorax should be managed with chest drain insertion when needle aspiration fails or the patient is symptomatic beyond minimal symptoms 2, 3
• In trauma settings, chest drain placement is required when pleural disruption causes pneumothorax, hemothorax, or hemopneumothorax 4
• Consider pleural vent systems for low-risk patients with local expertise to enable home management 1

Pleural Effusions Requiring Drainage

• Significant pleural infection: Insert a drain at the outset rather than performing repeated thoracentesis 1
• Enlarging or symptomatic parapneumonic effusions: These should not be managed by antibiotics alone, as conservative treatment results in prolonged illness and hospital stay 1
• Complicated parapneumonic effusions with thick fluid and loculations or frank empyema (overt pus) require drain insertion 1
• Massive effusions (more than 2/3 of hemithorax) causing severe dyspnea or hypoxemia 5

Hemothorax

• Chest drain insertion is indicated for hemothorax from trauma, though recent evidence suggests small-bore drains may perform adequately despite traditional use of large-bore drains 4

Effusions in Ventilated Patients

• Any significant pleural effusion in mechanically ventilated patients warrants drain insertion 5

When NOT to Insert a Chest Drain

Situations Where Thoracentesis is Preferred

• Uncomplicated transudative effusions: These rarely require drain insertion and can be managed with simple thoracentesis 5
• Malignant effusions without planned pleurodesis: Unless the patient needs an indwelling pleural catheter for recurrent drainage, simple thoracentesis is often sufficient 1, 5
• Small, asymptomatic pleural effusions: The risk-benefit should favor observation or simple aspiration 1
• Diagnostic purposes only: When malignancy is suspected and the patient is a candidate for systemic therapy, diagnostic aspiration is sufficient unless the effusion is symptomatic 1

Key Caveat

A retrospective study found that 45.4% of chest drains were potentially avoidable when routine drain insertion was the default strategy, with unnecessary drains causing major complications in 21.5% of cases 5. This underscores the importance of adhering to specific indications rather than defaulting to drain insertion.

Technical Considerations Once Indication is Established

Drain Size Selection

• Small-bore drains (≤14F) should be used as first-line therapy for pneumothorax and most pleural effusions, with success rates of 84-97% 2, 3, 6
• Large-bore drains may be necessary only when small tubes fail due to persistent air leaks exceeding tube capacity or when significant pleural fluid with debris is present 2, 3
• For pediatric pleural infections, small bore drains (including pigtail catheters) should be used whenever possible to minimize patient discomfort 1

Pre-Insertion Requirements

• Ultrasound guidance should be used to guide thoracentesis or drain placement 1
• Chest drains should be inserted by adequately trained personnel with a suitable assistant and trained nurse available 1
• Correct any coagulopathy or platelet defect before insertion where possible 1

Special Populations

• Children with significant pleural infection: A respiratory paediatrician should be involved early in care 1
• Recurrent malignant pleural effusions: Consider indwelling pleural catheters to avoid repeated hospital drainage or admission 1, 7

Common Pitfalls to Avoid

• Do not perform repeated thoracentesis when a child has significant pleural infection—insert a drain at the outset 1
• Never use a trocar for chest tube insertion; use blunt dissection or Seldinger technique instead 6
• Do not routinely insert drains for all pleural effusions without meeting specific criteria, as this leads to avoidable complications 5
• Avoid delaying active treatment in favor of conservative management for enlarging effusions, as this prolongs illness 1