Chest Tube Removal Technique
Chest tubes should be removed during either end-expiration or during a Valsalva maneuver, using a brisk, firm movement. 1
Evidence-Based Recommendation
The British Thoracic Society guidelines explicitly state that chest tube removal should be performed "either while the patient performs Valsalva's manoeuvre or during expiration, with a brisk firm movement." 1 This represents the highest quality guideline evidence available on this specific procedural question.
Clinical Rationale
The physiologic principle behind removal during expiration or Valsalva is to minimize the risk of air entry into the pleural space at the moment the tube is withdrawn. 1 During expiration or Valsalva, intrathoracic pressure is positive relative to atmospheric pressure, creating an outward pressure gradient that prevents atmospheric air from being sucked into the pleural cavity through the chest tube tract. 1
Research Evidence Shows Equivalence
A prospective randomized trial of 102 chest tubes in trauma patients directly compared end-inspiration versus end-expiration removal and found no significant difference in recurrent pneumothorax rates (8% vs 6%, p=1.0). 2 Both methods proved equally safe, with similar rates requiring repeat tube insertion (2 tubes vs 1 tube). 2 This research supports that the timing of removal (inspiration vs expiration) is less critical than proper technique execution. 3
Essential Procedural Elements
Beyond the respiratory phase, several critical components ensure safe removal:
Adequate analgesia must be provided before removal, with evidence showing topical anesthetic cream applied 3 hours prior is as effective as IV morphine for pain control. 1
The removal motion must be brisk and firm to minimize the time the chest wall defect remains open to atmosphere. 1
For surgically placed drains with closure sutures, approximate the suture while removing the drain to immediately seal the tract. 1
A chest radiograph should be obtained shortly after removal (within 5-12 hours) to detect any pneumothorax that may have developed. 4
Common Pitfall to Avoid
The most important technical error is slow, hesitant tube removal, which prolongs the time the pleural space communicates with atmosphere and increases pneumothorax risk. 1 The removal must be executed as a single, confident motion regardless of whether it occurs during expiration or Valsalva. 1, 3
Practical Application
In clinical practice, removal during expiration is often easier to coordinate than Valsalva in postoperative or sedated patients who may not reliably perform the maneuver. 3 For cooperative patients, either technique is acceptable. 1, 2 The key is ensuring the patient does not actively inhale during the removal moment, as this creates negative intrathoracic pressure favoring air entry. 1