What are the key findings to look for on a chest X-ray (CXR) in a patient with a chest tube?

Key Findings on Chest X-Ray After Chest Tube Placement

Obtain a portable chest radiograph immediately after chest tube insertion to assess tube position, as approximately 10% of chest tubes are malpositioned on initial post-insertion imaging. 1

Essential Radiographic Findings to Evaluate

Chest Tube Position and Course

• Verify the tube enters the intrathoracic space and follows an appropriate trajectory within the pleural cavity 1
• Confirm the tube tip is not positioned in a fissure (intrafissural placement), which can occur but may still function adequately if drainage is effective 2
• Ensure the tube is not kinked or malpositioned extrapleurally, particularly important with small soft drains in mobile patients 2
• Check that all side holes of the chest tube are within the pleural space 1

Pneumothorax Assessment

• Evaluate for residual or recurrent pneumothorax, looking for the visceral pleural line separated from the chest wall 1
• Assess the size and location of any remaining pneumothorax 1
• Monitor for tension pneumothorax signs including mediastinal shift away from the affected side and hemidiaphragm depression 2

Pleural Fluid Evaluation

• Assess for residual pleural effusion or hemothorax, which appears as blunting of the costophrenic angle or layering opacity 1
• Look for air-fluid levels that may indicate hydropneumothorax 1

Lung Re-expansion

• Confirm adequate lung re-expansion by evaluating lung volumes and comparing to the contralateral side 1
• Look for complete apposition of visceral and parietal pleura 2

Associated Complications

• Identify subcutaneous emphysema along the chest wall, which appears as lucent streaks in the soft tissues 1
• Evaluate for iatrogenic complications including tube placement into solid organs (rare but serious) 1
• Check for mediastinal widening or abnormal cardiac silhouette that might suggest mediastinal injury 1

Clinical Correlation Points

The absence of respiratory swing in the chest tube drainage system may indicate extrapleural positioning or complete lung re-expansion and should prompt radiographic reassessment. 2

If the tube appears malpositioned but is functioning adequately (good drainage, no clinical deterioration), serial chest radiographs for ongoing monitoring may be sufficient rather than immediate repositioning. 2

Critical Safety Reminder

Never clamp a bubbling chest tube, as this can cause fatal tension pneumothorax. 2 This clinical pearl is essential even though it's not directly visible on the CXR—the radiographic findings must always be interpreted in the clinical context of tube function.

Follow-up Imaging Considerations

Routine chest radiographs after chest tube removal have limited utility, as complications (particularly pneumothorax) occur at low rates (0.25-4% requiring reinsertion) and are usually clinically predicted. 1 However, the ACR Appropriateness Criteria note this remains controversial, and selective imaging based on clinical suspicion is reasonable. 1