What is the best course of action for a patient with a clotted chest tube (tubular drainage device)?

Management of a Clotted Chest Tube

Do not manually strip, milk, or break the sterile field to clear a clotted chest tube—instead, use active clearance technology or replace the tube if necessary. 1

Immediate Assessment

When confronting a clotted chest tube, first evaluate the clinical consequences rather than reflexively manipulating the tube:

• Assess for retained blood syndrome by checking for signs of cardiac tamponade (hypotension, elevated jugular venous pressure, muffled heart sounds), hemothorax (decreased breath sounds, dullness to percussion), or pericardial effusion (new dyspnea, chest discomfort) 1
• Quantify drainage cessation by documenting when output stopped and comparing current versus expected drainage volumes 2
• Obtain urgent echocardiography if tamponade is suspected, as this is a life-threatening complication requiring immediate intervention 1

What NOT to Do (Class III Recommendations)

The Society for Enhanced Recovery After Cardiac Surgery provides explicit contraindications:

• Do not strip or milk the chest tube, as meta-analyses of randomized trials demonstrate this technique is ineffective and potentially harmful, generating dangerously high negative intrathoracic pressures (up to -400 cmH2O) that can cause tissue injury, hemorrhage, or disruption of bypass grafts 1, 3
• Do not break the sterile field to manually aspirate clots, as this significantly increases infection risk without proven efficacy 1
• Do not simply observe if the patient is clinically unstable or has evidence of retained blood complications 1

Recommended Interventions

First-Line: Active Clearance Technology

Utilize active chest tube clearance systems that employ an internal looped guidewire to break up clots within the tube without breaking sterility (Class I recommendation, Level B evidence) 1:

• These devices maintain patency by mechanically disrupting clots from within the closed drainage system 4, 5
• Propensity-matched studies demonstrate 67% reduction in drainage procedures for pleural effusions (8.1% vs 22%, P<0.001) and 32% reduction in postoperative atrial fibrillation (25% vs 37%, P=0.011) 1
• Animal studies show significantly improved drainage (670±105 mL vs 239±131 mL, P=0.01) and reduced retained blood (150±107 mL vs 571±248 mL, P=0.04) compared to standard tubes 5

Second-Line: Tube Replacement

If active clearance is unavailable or the tube remains obstructed:

• Replace the chest tube under sterile conditions with appropriate imaging guidance (ultrasound preferred) 6
• Consider larger bore tubes (24F-28F) if significant ongoing bleeding is expected, though 16F-22F is adequate for most stable patients 1, 6
• Ensure proper positioning using post-placement chest radiography 2

Adjunctive Measures

For specific clinical scenarios:

• Thrombolytic therapy (alteplase) may be considered for occluded tubes, though this is primarily studied for central venous catheters rather than chest tubes—2 mg instilled into the catheter lumen with assessment at 30 and 120 minutes can restore function in 67-85% of cases 7
• Urgent surgical consultation is mandatory if drainage was >200 mL/hour before cessation, suggesting possible tamponade requiring operative exploration 2

Clinical Context: Why Clotting Occurs

Understanding the mechanism helps prevent recurrence:

• Chest tube clogging occurs in up to 36-40% of patients after cardiac surgery, making this an expected rather than exceptional complication 1
• Retained blood promotes inflammation through hemolysis and oxidative stress, triggering postoperative atrial fibrillation (incidence increases from 17% to 32% with inadequate drainage) 1
• Prevention is superior to treatment—consider active clearance systems prophylactically in high-risk patients (those with significant intraoperative bleeding, coagulopathy, or multiple chest tubes) 1

Evidence Quality Note

The recommendations against manual manipulation represent Class IIIA (harm), Level B-R (randomized evidence), while active clearance recommendations are Class I (benefit), Level B-NR (non-randomized evidence) 1. Multiple randomized trials from 1986-1991 consistently showed no benefit from milking or stripping techniques, with some demonstrating potential harm 3, 8. The active clearance technology, while supported by lower-level evidence, addresses an unmet clinical need without the documented risks of manual manipulation 1.