When is it appropriate to remove a chest tube, in terms of drainage volume, using a conservative approach, specifically when the drainage is less than what amount, typically measured in milliliters per hour (mL/h) or other units of fluid output?

From the Guidelines

The conservative approach to removing a chest tube would be to remove when the drainage is less than 300 mL per 24 hours. This threshold is supported by recent studies, including Zhang et al. 1, which demonstrated the equivalence of drain removal in the absence of air leaks for fluid drainage < 300 mL/24h compared to fluid drainage < 100 mL/24h in terms of complications and re-drainage. Key considerations for chest tube removal include:

• Ensuring the absence of air leaks
• Evaluating the volume and appearance of the fluid drained over 24 hours
• Assessing the persistence of pleural effusion on chest x-ray
• Removing the chest tube during expiration or while the patient performs the Valsalva maneuver to prevent air entry into the pleural space
• Applying an occlusive petroleum gauze dressing secured with tape to create an airtight seal after removal
• Obtaining a chest X-ray following tube removal to confirm the absence of pneumothorax or fluid reaccumulation, as reported by Bjerregaard et al. 1. Some studies suggest even higher thresholds, such as 350 mL/day 1 or 500 mL/day 1, but 300 mL per 24 hours appears to be a commonly cited and reasonable threshold for chest tube removal, balancing the risks of premature removal with the benefits of earlier tube removal, including reduced pain scores, analgesic consumption, drainage time, and length of stay 1.

From the Research

Chest Tube Removal Criteria

The conservative approach to removing a chest tube is based on the drainage volume. Key points to consider include:

• The optimal timing for tube removal is still a matter of controversy 2
• A study found that increasing the threshold of daily drainage to 200 mL before removing the chest tube did not markedly affect drainage, hospitalization time, or overall costs, nor did it increase the likelihood of major pleural fluid reaccumulation 3
• This suggests that a drainage volume of less than 200 mL/day could be a reasonable threshold for chest tube removal

Drainage Volume Thresholds

Different studies have explored various drainage volume thresholds, including:

• 100 mL/d 3
• 150 mL/d 3
• 200 mL/d 3, which was found to be a suitable threshold for chest tube withdrawal decision for uninfected pleural fluid with no evidence of air leaks

Clinical Considerations

When deciding on chest tube removal, clinicians should consider factors such as:

• The presence of air leaks or other complications 2
• The patient's overall clinical condition and symptoms 4, 5
• The risk of pneumothorax or other adverse events 5, 6