What are the indications for intercostal (chest tube) drainage?

Indications for Intercostal (Chest Tube) Drainage

Intercostal chest tube drainage is indicated for pneumothorax when simple aspiration fails or is inappropriate, for secondary pneumothorax in symptomatic patients, and for drainage of significant pleural fluid collections including hemothorax, empyema, and malignant effusions. 1

Primary Indications by Clinical Scenario

Pneumothorax Management

Primary Spontaneous Pneumothorax:

• Insert a chest tube when simple aspiration is unsuccessful in controlling symptoms 1
• If more than 2.5 liters was aspirated during an unsuccessful aspiration attempt, proceed directly to tube drainage 1
• Attempt simple aspiration first as the initial intervention; only escalate to chest tube if this fails 1

Secondary Pneumothorax:

• Insert an intercostal tube in all cases except patients who are not breathless and have a very small pneumothorax (<1 cm or apical only) 1
• Patients with chronic lung disease have less successful outcomes with simple drainage procedures and require closer observation 1
• These patients warrant a lower threshold for chest tube insertion given their reduced respiratory reserve 1

Key Decision Point: Significant dyspnea requires intervention regardless of pneumothorax size 1

Pleural Fluid Collections

General Indications:

• Hemothorax requiring drainage 2, 3
• Pleural empyema 2, 3
• Symptomatic pleural effusions 2, 4
• Malignant pleural effusions, particularly when immediate pleurodesis is planned 2
• Chylothorax 4

Post-Surgical:

• Major thoracic surgery for drainage of air and fluid 3
• Post-operative monitoring of accumulation rates in the pleural space 5

Clinical Algorithm for Decision-Making

1. Assess if pneumothorax is primary or secondary 1

   • Primary: No underlying lung disease
   • Secondary: Chronic lung disease present

2. For primary pneumothorax:

   • Attempt simple aspiration first 1
   • If aspiration fails or patient remains symptomatic → insert chest tube 1
   • If >2.5L aspirated unsuccessfully → insert chest tube 1

3. For secondary pneumothorax:

   • If breathless OR pneumothorax >1 cm → insert chest tube 1
   • If not breathless AND very small (<1 cm/apical) → observe 1

4. For pleural effusions:

   • Symptomatic collections requiring drainage → insert chest tube 2
   • Empyema → insert chest tube 2, 3
   • Hemothorax → insert chest tube (consider large-bore) 2, 3

Technical Considerations

Tube Size Selection:

• Start with small-bore tubes (10-14F) for pneumothorax as they achieve 84-97% success rates and are as effective as large tubes 6, 1
• Reserve large-bore tubes (20-24F) for persistent air leaks after small tube failure, very large air leaks, or when pleural fluid is present 6, 1
• For hemothorax and malignant effusions requiring immediate pleurodesis, large-bore tubes may be preferred initially 2

Insertion Guidance:

• Use imaging guidance (bedside ultrasound or CT) for optimal placement 1, 2
• Insert at the site suggested by chest ultrasound 1
• Use blunt dissection for tubes >24F or Seldinger technique for smaller tubes 7, 2
• Never use a trocar or substantial force - this is the primary cause of catastrophic organ injury 7, 3

Critical Safety Considerations

Absolute Contraindications to Clamping:

• Never clamp a bubbling chest tube - this can convert a simple pneumothorax into life-threatening tension pneumothorax 6, 1, 7
• Clamping does not improve success rates or prevent recurrence 6

Infection Prevention:

• Use strict aseptic technique during insertion and all manipulations 6, 1
• Empyema occurs in 1% of insertions overall, up to 6% in trauma cases 6, 7
• Consider prophylactic antibiotics when prolonged drainage is anticipated 6

When to Refer:

• Pneumothoraces failing to respond within 48 hours should be referred to a respiratory physician 6
• Persistent air leaks exceeding 48 hours require specialist management 6, 1