From the Guidelines
No, chest tubes should not be clamped before removal. The standard practice is to remove chest tubes without clamping while the patient performs the Valsalva maneuver (holding their breath after a deep inhalation) 1. Clamping a chest tube before removal can potentially lead to tension pneumothorax, which is a life-threatening condition where air accumulates in the pleural space under pressure. When removing a chest tube, the healthcare provider should first ensure adequate pain control, then remove any securing sutures, and swiftly remove the tube during the patient's Valsalva maneuver. Immediately after removal, an occlusive dressing should be applied to the site. This approach minimizes the risk of air entering the pleural space during removal while allowing any accumulated air or fluid to exit through the tube until the moment of removal. The only exception might be certain specific clinical scenarios where temporary clamping may be indicated under close monitoring, but this is not standard practice for routine chest tube removal.
Key Considerations
- The absence of an intrathoracic air leak and minimal pleural fluid drainage (<1 mL/kg/24 h) are key criteria for chest tube removal 1.
- A chest radiograph should be performed after chest tube removal to ensure that the pneumothorax has not recurred 1.
- The decision to remove a chest tube should be based on clinical judgment and patient-specific factors, rather than a one-size-fits-all approach 1.
Clinical Implications
- Chest tube removal without clamping is a safe and effective practice that minimizes the risk of complications such as tension pneumothorax 1.
- Healthcare providers should be aware of the potential risks and benefits of chest tube removal and take a patient-centered approach to decision-making 1.
- Further research is needed to inform evidence-based guidelines for chest tube removal and to optimize patient outcomes 1.
From the Research
Clamping of Chest Tube Before Removal
- The practice of clamping the chest drain before removal in spontaneous pneumothorax appears to be safe, as observed in a study published in 2021 2.
- Clamping the chest tube before removal may avoid reinsertion in case of early recurrence, but it may also prolong hospital stay 2.
- A study found that clamping saved chest drain reinsertion in 11.8% of cases, and has the potential to save more if clamped for up to 24 hours 2.
- However, clamping may result in more early recurrences, and significantly more previous pneumothorax episodes were seen in the early recurrence group 2.
Management of Pneumothorax
- Pneumothorax is common in trauma, and has been found in up to 50% of severe polytrauma patients with chest injury 3.
- Patients with traumatic pneumothorax are typically treated with needle decompression or tube thoracostomy, but recent literature has found that many patients can be managed conservatively via observation, or with a smaller thoracostomy such as a percutaneous pigtail catheter rather than a larger chest tube 3.
- The management of pneumothorax and prolonged air leak involves conservative management, simple pleural aspiration or drainage, and interventional pulmonology techniques for treating persistent air leak and bronchopleural fistula 4.
Pleural Space Management
- Effective management of the pleural space is essential in thoracic trauma, and involves management of the pleural space in chest wall trauma, including pneumothorax and hemothorax, and chest tube placement 5.
- Video-assisted thoracoscopic surgery may be indicated in certain cases, and complications of pleural space management must be carefully managed 5.