In an adult or elderly patient with a history of thoracic surgery, trauma, or underlying lung disease and a clotted chest tube (chest drainage tube), should I perform a 1-view chest X-ray (CXR) or a 2-view CXR?

Chest Tube Malfunction: Imaging Approach

When a chest tube is clotted, perform a single-view (AP/PA) chest X-ray initially, as this is sufficient to assess tube position, residual pneumothorax or effusion, and lung re-expansion—the key clinical questions that determine immediate management.

Rationale for Single-View CXR

• A single anteroposterior (AP) or posteroanterior (PA) chest radiograph is the standard initial imaging for evaluating chest tube function and complications 1. This approach:

  • Confirms chest tube position and identifies displacement 2
  • Detects residual pneumothorax or hemothorax 2, 3
  • Assesses lung re-expansion 1
  • Evaluates for new complications 1

• Two-view chest X-rays (PA and lateral) add minimal clinical value in the acute setting of chest tube malfunction 4. The lateral view rarely changes management decisions when the frontal view already demonstrates tube position and pleural space status 1.

When to Escalate Imaging

If the single-view CXR shows concerning findings or clinical suspicion remains high despite normal radiograph, proceed directly to chest CT:

• CT is significantly superior to chest X-ray for detecting occult pneumothorax (sensitivity approaching 100% vs. 64-71% for CXR), hemothorax, and lung contusions 2, 3. CT detects major complications missed on chest X-ray in 65% of trauma patients 2.

• Specific indications for CT after initial CXR include:

  • Persistent symptoms despite apparently well-positioned tube on CXR 2
  • Suspected loculated fluid collections that may require additional drainage 1
  • Concern for underlying lung pathology (empyema, abscess) 1
  • Evaluation for surgical planning if tube replacement or thoracoscopy is being considered 1

Clinical Decision Algorithm

1. Obtain single-view (AP or PA) chest X-ray immediately 1
2. Assess the radiograph for:
   • Tube position (tip should be in pleural space, not kinked or displaced) 2
   • Residual air or fluid collection 2, 3
   • Lung expansion status 1
3. If CXR shows adequate tube position but clinical concern persists (ongoing air leak, continued drainage issues, respiratory distress), proceed to chest CT 2, 3
4. If tube is clearly malpositioned or kinked on CXR, clinical intervention (repositioning or replacement) takes priority over additional imaging 2

Common Pitfalls to Avoid

• Do not delay clinical intervention for additional imaging views if the tube is obviously malpositioned or the patient is clinically deteriorating 2. Management decisions should be based on clinical status combined with single-view radiograph findings.

• Do not assume a normal single-view CXR excludes all complications—CT detects additional significant findings in 35.6% of patients with initially negative chest X-rays 4, 3. If symptoms persist despite reassuring CXR, obtain CT.

• Avoid routine two-view chest X-rays as they increase radiation exposure and cost without improving clinical decision-making in the acute setting 4. Reserve lateral views for specific anatomic questions that cannot be answered on frontal view alone.