09. Chest Tubes

  • Indications: clinically significant pneumothorax, empyema or complicated para-pneumonic effusions, hemothorax, chylothorax, malignant pleural effusion, recurrent or large pleural effusions.
  • Placement: typically Seldinger pigtail (smaller caliber) chest tubes are placed by interventional radiology or pulmonary. Consider larger chest tubes by thoracic surgery if pigtail chest tubes are ineffective or emergent indication. Permanent tunneled pleural catheters can be placed for palliation of recurrent effusions.
  • Daily management: make sure the tube is not kinked on bedside exam, track output (appearance, hourly and daily volume); evaluate for tidaling and/or leak, positioning, dressing, etc. Depending on the indication, daily chest x-rays.
  • Vocabulary:
    • Tidaling: expected change in fluid column height with breathing (or change in pleural pressure).
    • Air leak: bubbling visible in water seal chamber (usually blue water). Suggests an open system either from the patient (pneumothorax) or the tubing integrity is impaired (latter if briefly occluding tube near insertion site doesn’t stop bubbling). There are different degrees of air leak (e.g. only with forced cough vs continuous).
    • Suction: continuous negative pressure (-20 mmHg) via pleural drainage box. Air or fluid will be removed from pleural space.
    • Water seal: water column allowing air to leave pleural space with exhalation.
    • Clamp: chest tube closed, no evacuation of air or fluid.
  • Troubleshooting:
    • Dislodged chest tube: can lead to pneumothorax through air entrainment and can be an emergency. Cover with gauze and tegederm (or other occlusive dressing) ASAP, then evaluate patient clinically and with CXR.
    • Malpositioned chest tube or worsening subcutaneous emphysema: evaluate with CXR and call the service that placed it.
    • Other: generally call service that placed tube for issues like absence of tidaling.
  • Thrombolytics: intrapleural administration of tPA and DNase should be considered for pleural sepsis. Little data to support lytic use outside of pleural sepsis but it is used with catheter plugging.
  • Removal of chest tube: will depend on indication of tube. If chest tube placed for pleural fluid drainage, remove if effusion is draining <200 ml/day (if empyema <20 ml/day) or if alternative plan is in place (e.g., switching to a permanent pleural catheter, pleurodesis, etc.), fluid is serous, lung has re-expanded on chest film, and clinical status has improved. There is varying practice in the removal of chest tubes placed for pneumothorax. Most will place chest tube on water seal (4 hours) with subsequent CXR; if no residual pneumothorax, chest tube is then clamped (4 hours) with repeat CXR. If no recurrent pneumothorax, the team that placed the chest tube will likely remove the tube.

 

Dev SP et al. Chest-tube Insertion. NEJM 2007; 358:750

Miller KS, Sahn SA. Chest tubes: Indications, technique, management, and complications. Chest 1987;91:258.

Rahman NM, Maskell NA, West A, et al. Intrapleural use of tissue plasminogen activator and DNase in pleural infection. N Engl J Med. 2011;365(6):518-526. doi:10.1056/NEJMoa1012740.