What are the next steps for a patient with a chest tube output of 10-20 ml/hour?

Chest Tube Output of 10-20 mL/Hour: Next Steps

A chest tube output of 10-20 mL/hour (240-480 mL/day) is within the safe range for removal in most clinical scenarios, and you should proceed with removal if there is no air leak and the patient is hemodynamically stable. 1

Immediate Assessment Required

Before proceeding with chest tube removal, verify the following criteria:

• Check for air leak: Confirm no bubbling in water seal for 6 hours or <20 mL/min air leak if using a digital drainage system 2
• Assess drainage character: Ensure the fluid is serous and not bloody, chylous, or purulent 1
• Verify hemodynamic stability: Patient must be stable for >12 hours with normal vital signs 2
• Confirm tube patency: Ensure the chest tube is not occluded, as sudden decreases in output may indicate blockage rather than resolution 3

Evidence-Based Removal Thresholds

Your patient's output falls well below the safe removal threshold:

• General threshold: Up to 450 mL/day is considered safe for chest tube removal across most clinical scenarios 1
• Post-cardiac surgery: Some centers safely remove tubes with output up to 8.5 mL/kg/24h without increased complications 1
• Post-lung resection: Drainage up to 450-500 mL/day of non-chylous fluid is acceptable 1
• Trauma patients: Removal is safe with output <300 mL/day 4

The traditional 200 mL/day threshold has been superseded by higher, evidence-based limits that reduce hospital length of stay without increasing readmission rates 1, 5

Clinical Context Matters

Post-cardiac surgery patients: If this is a mediastinal chest tube after cardiac surgery, be vigilant for tube occlusion. A sudden decrease in output may indicate clot formation rather than resolution, particularly in the first 24-48 hours postoperatively 3. Consider bedside echocardiography if there are any signs of tamponade physiology (hypotension, tachycardia, elevated jugular venous pressure, muffled heart sounds) 3

Post-thoracic surgery patients: For patients after lung resection, this output level is well within safe parameters for removal, provided there is no air leak 1, 2

Mechanically ventilated patients: Exercise caution and consider maintaining the tube longer, as these patients are at higher risk for large pleural air leaks 1

Removal Protocol

Once all criteria are met:

• Timing of removal: Tubes can be removed at either end-expiration or end-inspiration with equivalent safety 6
• No clamping trial needed: A drain-clamping test before removal is not advocated and should be avoided 7
• Post-removal monitoring: Obtain a chest X-ray 2-4 hours after removal only if clinically indicated (new symptoms, respiratory distress), not routinely 2

Critical Pitfalls to Avoid

• Do not remove with ongoing air leak: Regardless of low fluid volume, presence of an air leak is an absolute contraindication to removal 1, 2
• Do not ignore sudden output changes: A sudden decrease from higher output to 10-20 mL/hour may indicate tube occlusion rather than clinical improvement, especially in cardiac surgery patients 3
• Do not focus solely on volume: Always assess the quality of drainage—bloody or chylous fluid requires different management even at low volumes 1
• Do not delay removal unnecessarily: Keeping tubes in place longer than needed increases infection risk, pain, and hospital costs without clinical benefit 1, 5

If Removal Criteria Are Not Met

If air leak persists or patient is unstable:

• Continue monitoring output every 2-4 hours 2
• Reassess air leak status every 6-12 hours 2
• Verify tube patency if output suddenly decreases 3
• Consider digital drainage systems for more accurate assessment of air leak and fluid output 1