After coronary artery bypass graft surgery, should the patient exhale fully and hold their breath (perform a Valsalva maneuver) or inhale and hold the breath when the pleural chest tube is removed?

Chest Tube Removal Technique Post-CABG

Instruct the patient to inhale and hold their breath during chest tube removal after CABG surgery. 1

Evidence-Based Breathing Technique

The 2018 Critical Care Medicine guidelines specifically evaluated breathing-focused relaxation techniques during chest tube removal (CTR) in post-cardiac surgery patients and found that the optimal technique consists of instructing the patient to inhale and hold their breath for a moment, then breathe out and go limp as a rag doll, with the chest tube removed at the end of a yawn. 1 This approach achieved a clinically meaningful reduction in pain intensity (mean reduction of 2.5 cm on a 0-10 VAS scale) compared to standard removal techniques. 1

Why This Technique Works

• Inhalation creates positive intrathoracic pressure that helps prevent air entry into the pleural space during tube removal, reducing the risk of pneumothorax. 1

• The relaxation component (going limp as a rag doll and yawning) provides significant pain reduction during the procedure, which is particularly important given that CTR is one of the most painful procedures in the ICU setting. 1

• This technique was specifically validated in post-cardiac surgery ICU patients, making it directly applicable to your CABG population. 1

Contrasting Evidence from Thoracic Surgery

It's important to note that one study in pulmonary resection patients found that expiration was superior to inspiration for chest tube removal, showing lower rates of non-clinically significant pneumothorax (19% vs 32%). 2 However, this study involved thoracotomy patients after lung resection—a fundamentally different clinical scenario than post-CABG patients with intact lungs. The guideline evidence specifically addressing cardiac surgery patients takes precedence here. 1

Complete Removal Protocol

Pre-removal preparation:

• Ensure adequate analgesia with opioid administration timed 5 minutes before the procedure. 1
• Position the patient semi-recumbent or head-up to optimize respiratory mechanics. 3
• Pre-oxygenate with FiO2 of 1.0 to maximize oxygen stores. 3

During removal:

• Instruct the patient: "Take a deep breath in and hold it for a moment." 1
• Continue: "Now breathe out slowly and let your whole body go limp like a rag doll." 1
• Encourage the patient to start yawning. 1
• Remove the chest tube at the end of the yawn while the patient is relaxed. 1

Post-removal:

• Apply occlusive dressing immediately. 4
• Obtain chest X-ray to assess for pneumothorax or residual effusion. 4
• Monitor oxygen saturation, respiratory rate, and work of breathing. 3

Common Pitfalls to Avoid

• Do not remove the tube during forced Valsalva alone without the relaxation component—this increases pain and patient distress without additional benefit. 1

• Do not apply the thoracic surgery expiration technique to cardiac surgery patients, as the underlying pathophysiology and surgical approach differ significantly. 2

• Do not remove tubes without adequate pre-medication—the pain reduction from the breathing technique is enhanced when combined with appropriately timed opioid administration. 1

• Avoid early removal (before 24 hours) if drainage exceeds 100 cc in the last 8 hours, as this increases risk of residual effusion requiring intervention. 4

Clinical Outcomes

This inhalation-based relaxation technique is associated with:

• Reduced analgesic requirements in the 12-24 hours following removal. 4
• Lower incidence of atelectasis and pleural effusion on post-removal imaging. 4
• Earlier mobilization (23% walking at 48 hours vs 4% with later removal). 4
• No increase in hemodynamic instability during the removal procedure. 5