Chest Radiograph Confirmation After Chest Tube Placement
Obtain a portable chest radiograph immediately after chest tube insertion to confirm proper positioning and assess for complications. 1, 2, 3
Primary Recommendation
Portable chest X-ray is the standard imaging modality to confirm chest tube placement in ICU patients following support device placement. 1 The American College of Radiology designates this as "usually appropriate" for initial imaging after chest tube insertion. 1
Key Radiographic Assessment Points
After chest tube placement, the confirmatory chest X-ray must evaluate several critical elements:
Verify the tube enters the intrathoracic space with all side holes positioned within the pleural cavity, not in the chest wall or subcutaneous tissues. 2, 3
Assess for tube malposition, which occurs in approximately 10% of initial post-insertion imaging studies. 1, 2, 3 This represents a clinically significant rate that justifies routine imaging.
Evaluate for residual or recurrent pneumothorax by identifying the visceral pleural line separated from the chest wall and determining the size and location of any remaining air collection. 2
Check for residual pleural effusion or hemothorax, which appears as costophrenic angle blunting or layering opacity, and look for air-fluid levels suggesting hydropneumothorax. 2
Confirm adequate lung re-expansion by comparing lung volumes to the contralateral side and verifying complete apposition of visceral and parietal pleura. 2
Identify subcutaneous emphysema along the chest wall, appearing as lucent streaks in soft tissues, and evaluate for iatrogenic complications including inadvertent tube placement into solid organs. 2
Assess for mediastinal widening or abnormal cardiac silhouette that might indicate mediastinal injury. 2
Alternative Imaging Modalities
Ultrasound can visualize chest tube entry into the intrathoracic space with 100% accuracy using a high-frequency (10-5 MHz) linear transducer, with characteristic M-mode patterns distinguishing the tube from the pleural line. 1 However, the American College of Radiology panel did not reach consensus on recommending ultrasound as the primary confirmation method for chest tube placement. 1
CT imaging should be considered when there is sudden cessation of drainage, absence of respiratory swing in the chest tube, or clinical suspicion of malposition despite adequate-appearing radiograph. 3
Clinical Context
The evidence supporting routine post-insertion chest radiography is robust, with multiple studies demonstrating the 10% malposition rate. 1, 2, 3 This contrasts sharply with post-removal imaging, where routine chest X-rays have limited utility since complications requiring reinsertion occur at low rates (0.25-4%) and are usually clinically predicted. 1, 2, 3
Important Caveat
Do not rely solely on clinical assessment (auscultation, chest wall movement) to confirm chest tube position, as these bedside techniques lack the accuracy needed to detect malposition or complications that could impact patient morbidity and mortality. 2, 3 The radiographic confirmation is essential before assuming proper function of the chest tube drainage system.