What are the guidelines for chest tube insertion in patients with pneumothorax or pleural effusion?

Chest Tube Insertion Guidelines

Primary Recommendation for Pneumothorax

For large pneumothorax, insert a chest tube immediately; for small pneumothorax in clinically stable patients, attempt simple aspiration first and reserve chest tube insertion for aspiration failure or clinical instability. 1

Algorithmic Approach to Pneumothorax Management

Step 1: Size and Stability Assessment

• Large pneumothorax (>2 cm rim): Always insert chest tube and admit to hospital 1
• Small pneumothorax (<2 cm rim) + clinically stable: Attempt simple aspiration first 1
• Small pneumothorax + clinically unstable: Insert chest tube 1
• Secondary pneumothorax (underlying lung disease): Insert chest tube except for very small (<1 cm or apical) pneumothorax in non-breathless patients 1

Step 2: Aspiration Protocol (Primary Pneumothorax Only)

• Perform simple aspiration as first-line intervention for symptomatic primary pneumothorax 1
• If first aspiration fails but <2.5 L was aspirated, consider second aspiration attempt (successful in >33% of cases) 1
• If aspiration removes >2.5 L or patient remains symptomatic after aspiration, proceed directly to chest tube insertion 1

Step 3: Chest Tube Selection

• Small-bore catheters (≤14F): First-line choice for spontaneous pneumothorax with success rates of 84-97% 2, 3, 4
• Moderate-bore tubes (16F-22F): Consider for large pneumothorax in stable patients 2, 4
• Large-bore tubes (24F-28F): Required for mechanically ventilated patients due to high-volume air leaks from positive-pressure ventilation 2

Critical caveat: Never use small-bore catheters in intubated patients—the air leak volume from positive-pressure ventilation exceeds their capacity 2

Step 4: Initial Drainage Strategy

• Start with water seal (gravity) drainage without suction for most patients—this is the preferred initial approach 2
• Apply suction immediately only if: 2
  • Patient requires positive-pressure ventilation
  • Large persistent air leak present
  • Clinical instability despite tube placement
  • Anticipated bronchopleural fistula

Step 5: Suction Application (If Needed)

• Use high-volume, low-pressure suction systems exclusively at -10 to -20 cm H₂O 2
• Air flow capacity should be 15-20 L/min 2
• Avoid high-pressure systems—they cause air stealing, hypoxemia, or perpetuate air leaks 2

Important timing: For stable patients on water seal, observe for 48 hours before applying suction 2

Special Population: Pleural Effusion

• Insert chest tube for large exudative effusions, empyemas, hemothoraces, or chylothoraces 5
• Small-bore catheters (≤14F) are equally effective as larger tubes for simple effusions with fewer complications 3
• Remove chest tube when drainage is <100 mL/24 hours for malignant effusions or <1 mL/kg/24 hours for other effusions 3

Critical Safety Principles

Never Clamp a Bubbling Chest Tube

A bubbling chest tube should never be clamped—this can convert a simple pneumothorax into life-threatening tension pneumothorax, especially in ventilated patients. 1, 2

• If clamping is absolutely necessary for non-bubbling tubes, it must be under respiratory physician or thoracic surgeon supervision in a specialist ward 1
• If patient becomes breathless or develops subcutaneous emphysema with clamped drain, unclamp immediately 1

Avoid Trocar Use

• Sharp metal trocars significantly increase risk of fatal organ penetration (lung, stomach, spleen, liver, heart, great vessels) 1
• Use blunt dissection technique or Seldinger technique instead 1

Pain Management

• Inject intrapleural local anesthetic (20-25 mL of 1% lidocaine) as bolus at insertion and every 8 hours as needed—this significantly reduces pain without affecting blood gases 1

Escalation Timeline

• At 48 hours: Refer to respiratory specialist if pneumothorax fails to respond or persistent air leak continues 2
• At 2-4 days: Consider surgical referral for patients with underlying lung disease, large persistent air leak, or failure of lung re-expansion 2
• At 5-7 days: Standard surgical referral for persistent air leak in patients without pre-existing lung disease 2

Recurrence Prevention

• First pneumothorax: Do not perform pleurodesis—inappropriate management due to concerns about future lung transplant candidacy 1
• Recurrent large pneumothorax: Perform pleurodesis to prevent further recurrence 1

Common Pitfalls to Avoid

• Using small-bore catheters in mechanically ventilated patients (inadequate for air leak volume) 2
• Applying excessive suction pressure (>-20 cm H₂O) causing re-expansion pulmonary edema 2
• Removing chest tube before drainage adequately decreases, risking reaccumulation 3
• Failing to recognize persistent air leak before tube removal, leading to pneumothorax recurrence 3
• Routinely placing chest tubes in small pneumothorax with stable patients—observation may be more appropriate given pain and morbidity of tube placement 1