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 cause 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 prepare an occlusive dressing, have the patient perform the Valsalva maneuver, quickly remove the tube, and immediately apply the occlusive dressing. This technique allows for proper air evacuation until the moment of removal and minimizes the risk of air re-entering the pleural space. The Valsalva maneuver increases intrathoracic pressure, which helps prevent air entry during the brief moment between tube removal and dressing application.
Key considerations for chest tube removal include:
- Absence of an intrathoracic air leak
- Pleural fluid drainage of less than 1 mL/kg/24 h, usually calculated over the last 12 hours 1
- A chest radiograph demonstrating complete resolution of the pneumothorax and no clinical evidence of an ongoing air leak 1
After removal, the site should be monitored for signs of pneumothorax recurrence or other complications. It is essential to follow a staged approach to chest tube removal, ensuring that the air leak into the pleural space has resolved and that there is no clinical evidence of an ongoing air leak 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.