What should the chest tube output be before removing the tube?

Chest Tube Removal Criteria

Chest tubes should be removed when drainage is less than 100-150 mL per 24 hours in adults with malignant pleural effusions, or less than 1 mL/kg/24 hours (typically 25-60 mL total) in pediatric patients, provided there is no air leak and complete lung re-expansion. 1

Adult Patients

Standard Removal Thresholds

For malignant pleural effusions, the American Thoracic Society recommends removal when:

• 24-hour drainage is 100-150 mL or less 1
• Complete lung expansion is confirmed radiographically 1
• No evidence of air leak 1

For pneumothorax management, the American College of Chest Physicians consensus states:

• Remove when there is no intrathoracic air leak 1
• Complete resolution of pneumothorax on chest radiograph 1
• Suction should be discontinued first, then observe for 5-12 hours before removal 1

Higher Threshold Evidence

Recent research supports higher output thresholds may be safe:

• A randomized trial demonstrated that removal at ≤200 mL/day did not increase reaccumulation rates (5.4%) compared to 100 mL/day (9.1%) or 150 mL/day (13.1%) 2
• Trauma patients tolerated removal with output up to 300 mL/day without increased complications 3
• Post-thoracoscopic surgery patients were safely managed with removal at ≤400 mL/24 hours 4

Pediatric Patients

The Pediatric Infectious Diseases Society/Infectious Diseases Society of America guidelines specify:

• Less than 1 mL/kg/24 hours, calculated over the last 12 hours 1
• This typically equals 25-60 mL total in 24 hours 1
• No intrathoracic air leak present 1
• Usually accomplished within 48-72 hours after operation or fibrinolysis completion 1

Critical Pre-Removal Steps

Staging Process for Removal

1. Confirm complete lung re-expansion on chest radiograph 1
2. Discontinue suction and place to water seal 1
3. Observe for 5-12 hours (62% of expert consensus) to ensure no pneumothorax recurrence 1
4. Verify no clinical evidence of ongoing air leak 1

Tube Clamping Controversy

• 53% of experts never clamp the chest tube to detect air leaks 1
• The remaining 47% would clamp approximately 4 hours after last evidence of air leak 1
• Regardless of clamping, repeat chest radiograph before removal 1

Special Circumstances

Excessive Drainage After Pleurodesis

If drainage remains ≥250 mL/24 hours after 48-72 hours post-pleurodesis:

• Consider repeat talc instillation at the same initial dose 1
• Do not remove tube until drainage decreases appropriately 1

Post-Surgical Thoracoscopy

For video-assisted thoracoscopic surgery (VATS):

• Early removal (within 24 hours) is safe in 58.8% of patients when drainage <400 mL/24h 4
• Some centers successfully remove tubes with drainage <100 mL/hour in immediate post-op period 5

Common Pitfalls to Avoid

Premature removal (before adequate drainage reduction) leads to:

• Fluid reaccumulation requiring thoracentesis 1, 6
• Pneumothorax recurrence 1, 6

Failure to recognize persistent air leak results in:

• Pneumothorax recurrence after removal 1, 6
• Need for tube reinsertion 1

Removing tube with loculated effusions without adequate drainage:

• May require fibrinolytic therapy or VATS before removal 1
• Longer drainage times are expected 1, 6

Practical Algorithm

1. Check daily output: Document 24-hour drainage volume
2. Adult threshold: <100-150 mL/24h (malignant effusion) or <200 mL/24h (general surgery/trauma)
3. Pediatric threshold: <1 mL/kg/24h (typically 25-60 mL total)
4. Verify no air leak: Observe water seal chamber for bubbling
5. Confirm lung expansion: Obtain chest radiograph
6. Discontinue suction: Place to water seal for observation period
7. Wait 5-12 hours: Repeat radiograph to confirm no reaccumulation
8. Remove tube: If all criteria met