What is the maximum duration a chest tube can be left in place?

Maximum Duration for Chest Tube Placement

Chest tubes should generally be removed within 20 days of placement, as duration beyond this threshold significantly increases the risk of empyema and other serious complications, with a nearly threefold increased risk of empyema development after 20 days. 1

Evidence-Based Duration Thresholds

Critical Safety Limit

• The 20-day threshold represents a critical inflection point where complications escalate dramatically 1
• Patients with chest tubes in place beyond 20 days face substantially higher rates of:
  • Empyema development (nearly 3-fold increased odds) 1
  • Hospital readmission (19.4% overall readmission rate in prolonged air leak patients) 1
  • Need for surgical reintervention (22.4% of readmitted patients) 1
  • Mortality (6.1% of readmitted patients died) 1

Standard Management Timeline for Pneumothorax

Primary Spontaneous Pneumothorax:

• Clamp the chest tube approximately 4 hours after the last evidence of air leak 2
• Obtain chest radiograph 5-12 hours after air leak cessation to confirm no recurrence 2
• Remove tube if radiograph confirms resolution 2

Secondary Spontaneous Pneumothorax:

• Clamp the tube 5-12 hours after the last evidence of air leak 2
• Obtain chest radiograph 13-23 hours after the last air leak evidence 2
• This longer observation period reflects the higher risk profile in patients with underlying lung disease 2

When to Escalate Care

If air leak persists beyond 4 days:

• Evaluate for surgical intervention rather than continuing conservative management 2
• Patients with underlying lung disease (COPD, secondary pneumothorax) may require earlier intervention at 2-4 days due to higher risk of persistent air leak 3

If pneumothorax fails to respond within 48 hours or persistent air leak exceeds 48 hours:

• Refer to a respiratory specialist 3

Outpatient Management Considerations

While outpatient chest tube management is feasible in selected patients, it carries significant risks:

• Overall failure rate requiring hospital admission: 4.2% 4
• However, modern data shows 19.4% readmission rate with serious complications including empyema, need for surgery, and death 1
• The key distinction is that older studies (1997) reported lower complication rates, but more recent multicenter data (2022) reveals substantially higher morbidity 1, 4

Absolute Contraindications to Prolonged Duration

Never clamp a bubbling chest tube - this may lead to tension pneumothorax, a potentially fatal complication 2

Practical Algorithm

1. Days 0-4: Standard chest tube management with water seal or suction as indicated 5, 3
2. Day 4: If air leak persists, consider surgical consultation 2
3. Days 5-20: If conservative management continues, aggressive monitoring for complications 1
4. Day 20: Strong consideration for tube removal or surgical intervention regardless of air leak status, given exponential rise in empyema risk 1

Common Pitfalls

• Allowing tubes to remain in place "just a few more days" beyond 20 days dramatically increases infection risk 1
• Failing to recognize that chest tube duration itself is an independent predictor of readmission and empyema, separate from the underlying pathology 1
• Assuming outpatient management is uniformly safe - while feasible, it requires careful patient selection and close follow-up 1, 4