Should a chest tube be placed on suction for a patient with a pneumothorax?

Should a Chest Tube Be Placed on Suction for Pneumothorax?

Start with water seal (gravity) drainage without suction for most patients with pneumothorax after chest tube insertion, then apply suction only if specific high-risk features are present or the lung fails to re-expand within 48 hours. 1

Initial Management Algorithm

For stable, non-ventilated patients with spontaneous pneumothorax:

• Insert the chest tube and connect it to water seal (gravity) drainage initially without suction 1
• Observe for 48 hours on water seal alone if the patient remains clinically stable 1
• This approach is the preferred initial strategy supported by the American College of Chest Physicians 1

Immediate Indications to Apply Suction

Apply suction immediately or early if any of the following are present:

• Patient requires positive-pressure ventilation (intubated patients) 1, 2
• Clinical instability with a large pneumothorax 1
• Anticipated or confirmed bronchopleural fistula 1, 2
• Large-bore chest tubes (24F-28F) are mandatory for ventilated patients due to high-volume air leaks 1, 2

Delayed Suction Application (After Initial Water Seal Trial)

Apply suction at 48 hours if:

• Persistent air leak continues beyond 48 hours 1
• Incomplete lung re-expansion occurs despite water seal drainage 1
• The lung fails to re-expand quickly with water seal alone 1

Technical Specifications When Suction Is Required

Use high-volume, low-pressure suction systems exclusively:

• Set suction pressure at -10 to -20 cm H₂O 3, 1, 2
• Ensure air flow capacity of 15-20 L/min 3, 1
• Avoid high-pressure systems as they cause air stealing, hypoxemia, or perpetuate persistent air leaks 3, 1

Critical Safety Considerations

Timing matters to prevent re-expansion pulmonary edema:

• Adding suction too early after chest tube insertion, particularly for primary pneumothorax present for several days, may precipitate re-expansion pulmonary edema 3, 1
• This risk is especially relevant when pneumothorax has been present for an extended period before treatment 3

Never clamp a bubbling chest tube:

• Clamping can convert a simple pneumothorax into life-threatening tension pneumothorax, particularly in ventilated patients 1, 2
• Even non-bubbling tubes should not be routinely clamped in ventilated patients 2

Special Populations Requiring Earlier Intervention

Patients with underlying lung disease (COPD, secondary pneumothorax):

• May require earlier suction application at 2-4 days rather than 5-7 days 1
• Higher risk of persistent air leak necessitates more aggressive management 1

Care Environment Requirements

Patients requiring suction must be managed in specialized settings:

• Place patients in areas with specialist nursing experience available 3
• Management should occur on specialized lung units with experienced medical and nursing staff trained in chest drain management 1, 2
• Complex drain management requires expertise in suction adjustment, drain repositioning, and recognition of complications 1, 2

Escalation Timeline

Refer to respiratory specialist:

• At 48 hours if pneumothorax fails to respond or persistent air leak continues 1
• Consider earlier surgical referral (2-4 days) in patients with underlying disease, large persistent air leak, or failure of lung to re-expand 3
• Standard surgical referral for persistent air leak should occur at 5-7 days in those without pre-existing lung disease 3

Common Pitfalls to Avoid

• Do not use small-bore catheters (≤14F) in ventilated patients as they are inadequate for the air leak volume generated by positive-pressure ventilation 1
• Avoid excessive suction pressure (>-20 cm H₂O) as it can cause re-expansion pulmonary edema or perpetuate air leaks 1, 2
• Do not apply routine immediate suction for spontaneous pneumothorax without specific indications, as there is no evidence supporting this practice 1