Should a functioning chest drain in a patient with empyema be removed or repositioned if one hole appears extra-pleural on radiographic imaging?

Management of Chest Drain with Extra-Pleural Positioning on Imaging

Direct Answer

An adequately functioning chest drain should NOT be removed or repositioned based solely on radiographic appearance, even if one drainage hole appears extra-pleural, as long as the drain is effectively draining fluid and the patient is clinically improving. 1

Clinical Reasoning and Evidence

Primary Guideline Recommendation

The British Thoracic Society explicitly states that "an effectively functioning drain should not be repositioned solely because of its radiographic appearance" in their guidelines for management of pleural infection in children 1. This principle applies equally to adult empyema management 1.

The key determinant is clinical function, not radiographic position. 1

When to Assess Drain Function

You should evaluate whether the drain is truly "adequately functioning" by checking:

• Active drainage of fluid: The drain should be producing pleural fluid output 1
• Respiratory swing: Fluid in the chest tube should move with respiration, confirming intra-pleural position 1
• Clinical improvement: Patient should show resolution of fever, decreased sepsis, and improved symptoms 1
• Absence of obstruction: No sudden cessation of drainage suggesting blockage or kinking 1

When Imaging Should Prompt Action

While radiographic appearance alone should not dictate removal, imaging becomes critical when drainage ceases or is inadequate:

• If drainage stops abruptly: First check for kinking at the skin level (common with small-bore drains), then flush with 20-50 ml normal saline to ensure patency 1
• If poor drainage persists after flushing: Obtain contrast-enhanced CT scanning to assess tube position, identify undrained locules, and evaluate for pleural peel 1, 2
• If imaging shows significant residual fluid with no drainage: The drain should be removed and replaced if necessary 1

The Extra-Pleural Hole Scenario

If one drainage hole appears extra-pleural but the drain is still functioning (draining fluid, showing respiratory swing, patient improving clinically), leave it alone. 1

The concern with extra-pleural positioning is:

• Continuous bubbling on suction: May indicate one hole is open to atmosphere rather than true pneumothorax 1
• Risk of subcutaneous emphysema: If air is being introduced into soft tissues
• Ineffective drainage: If the intra-pleural holes are insufficient

However, if other holes remain intra-pleural and the drain is working, the radiographic finding alone does not mandate intervention. 1

Critical Pitfalls to Avoid

• Do not reposition a functioning drain unnecessarily: This risks creating additional trauma, introducing infection, or losing effective drainage 1
• Do not rely on frontal radiographs alone: Lateral views are essential, as frontal radiographs identified only 1 of 21 malpositioned tubes in one study, while lateral views identified 8 of 9 3
• Do not ignore sudden cessation of drainage: This usually indicates obstruction (kinking or blockage) rather than resolution, and must be addressed 1
• Do not clamp a bubbling drain: If continuous bubbling occurs, determine if it represents pneumothorax or an extra-pleural hole before any intervention 1

When to Escalate Care

If despite an apparently well-positioned drain (or even a partially extra-pleural but functioning drain), the patient shows:

• Persistent sepsis at 5-8 days despite drainage and antibiotics 4
• Organized empyema with thick pleural peel on CT 2, 4
• Multiloculated collections not responding to fibrinolytics 2, 5

Early surgical consultation is warranted, as these indicate failure of conservative management regardless of drain position 4, 5.