During chest tube removal, should the patient hold a deep inspiratory breath or an expiratory breath?

Chest Tube Removal: Expiration is Preferred

Remove chest tubes at end-expiration rather than end-inspiration, as this technique reduces the incidence of post-removal pneumothorax. 1

Evidence-Based Recommendation

The highest quality evidence comes from a prospective randomized trial of 342 patients undergoing pulmonary resection, which demonstrated that end-expiration removal resulted in significantly fewer pneumothoraces (19%) compared to end-inspiration removal (32%, P = 0.007). 1 This study was closed early due to the clear superiority of the expiration technique. 1

Clinical Rationale

• End-expiration removal minimizes the pressure gradient between the pleural space and atmosphere at the moment the tube exits, reducing air entrainment into the pleural cavity. 1

• The physiologic advantage occurs because lung volume is at its lowest at end-expiration, creating less negative intrapleural pressure and therefore less driving force for air to enter the chest when the tube tract is exposed. 1

• Both techniques should incorporate a Valsalva maneuver during tube removal to further increase intrathoracic pressure and prevent air entry. 1

Supporting Evidence Across Populations

• A trauma surgery study of 102 chest tubes found no significant difference between end-inspiration (8% recurrence) and end-expiration (6% recurrence) techniques, suggesting both are safe in trauma populations. 2

• However, the pulmonary resection population demonstrated clear superiority of end-expiration technique, and this represents the highest quality evidence for elective chest tube removal. 1

• The technique of removal matters less than meticulous preparation and execution of the procedure itself. 3

Procedural Algorithm

1. Confirm readiness for removal: Ensure no air leak, minimal drainage (<200-400 mL/day), and stable chest radiograph. 4

2. Position the patient: Semi-upright or supine position is acceptable. 3

3. Instruct the patient: Have the patient take a deep breath, then exhale fully and hold at end-expiration. 1

4. Simultaneous Valsalva: Instruct the patient to perform a Valsalva maneuver (bear down) while holding their breath at end-expiration. 1

5. Swift removal: Remove the tube with one quick, smooth motion while the patient maintains the Valsalva at end-expiration. 1

6. Immediate occlusion: Apply an occlusive dressing immediately as the tube exits. 3

7. Post-removal imaging: Obtain a chest radiograph 2-4 hours after removal to assess for pneumothorax. 1

Critical Pitfalls to Avoid

• Do not remove tubes during inspiration in post-surgical patients, as this significantly increases pneumothorax risk (32% vs 19%). 1

• Do not delay removal in patients with small stable air leaks beyond 2-3 weeks, as outpatient management with portable devices is safe and effective. 4

• Do not apply suction for most small air leaks—water seal (passive drainage) is superior for managing minor leaks, reserving suction only for enlarging pneumothorax or subcutaneous emphysema. 4

• Do not assume the technique is unimportant—while one trauma study showed equivalence, the definitive pulmonary resection trial clearly favors expiration. 2, 1

Special Considerations

• For patients who cannot cooperate with breath-holding instructions, end-expiration removal remains preferred but may require sedation or careful timing with the respiratory cycle. 3

• Clinically significant complications requiring reintervention occur in only 1-3% of cases regardless of technique, but the expiration method minimizes even minor radiographic pneumothoraces. 1

• The presence of multiple risk factors (previous lung disease, multiple tubes, small residual pneumothorax at removal) does not change the preferred technique—expiration remains optimal. 2