Chest tubes.

Indications, technique, management

and complications.
K S Miller and S A Sahn
Chest 1987;91;258-264
DOI 10.1378/chest.91.2.258

The online version of this article, along with updated information and
services can be found online on the World Wide Web at:
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CHEST is the official journal of the American College of Chest Physicians. It

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Copyright 1987 American College of Chest Physicians

review
Chest Tubes*

yen the

past

K. Scott

M.D.;t

Miller,

years,

the

available

has expanded
transbronchial
and

Technique,

ten

techniques

tion,

Indications,

greatly.
biopsy,

newly

laser

pulmonologist.

Present-day

tients
often
monitoring
the

price

of this

complications,

invasion

particularly

ing

complication,
thorax).
Traditionally,
mothorax
thoracic

with
aspira-

of critically

ill

pa-

vessels
for
However,

is a definite

incidence

a potentially

life-threaten-

of invasive

procedures

individuals

performing

competent
management.

in

of

has been
handled
by
because
of the increased
by

the

such

pulmonologist,

tube
thoracostomy
and
In addition
to emergency

indications

for

tube

the
use

should

of

for

development
of tube
thoracostomy;
nique
ofinsertion,
drainage
systems,

the

(2) discuss
techand management

procedure.

was

space
tubes

emerged
*From

when
it was successfully
epidemic
empyemas.5

tubes

procedure

in

thoracotomy
acostomy

the

the

first

to consider

in the

midnineteenth

Division

of

Pulmonary

incision,
This
century.

and

Medical
University
of South
Carolina,
tAssistant
Professor
of Medicine.
lProfessor
of Medicine.
Reprint
requests:
Dr Sahn,
Division
Medicine,
Rm 812, Medical
University
ton 29405

Critical

drainage

of the

cautery,
concept

and
re-

Hunter,
Care

in

of Pulmonary/Critical
of South
Carolina,

thoracic

capable
for

of

drainage

of

markers,

Care
Charles-

employed

widely

used
to drain
The use of chest

care

Although

1922.6

the

Modern
their
earlier

was

used

reported

by

regularly

emergency
not become

post-

tube thorcommon-

Korean
OF

chest
tubes
counterparts.
varying
multiple

are

CHEST

TUBES

distinctly
They
are

different
from
made
of clear

internal

diameter,

with

drainage

holes,

and

distance

a radiopaque

stripe,
which
outlines
the proximal
drainage
hole. This
addition
permits
better
determination
of appropriate
tube
position
on a postplacement
chest
roentgenogram.

They

or obstruct

are

pliable

drainage.

but

not

Tube

supple

diameter

enough
can

to kink

vary

from

20

to 40 French
(5 to II mm internal
diameter)
for adults,
6 to 26 French
(2 to 6 mm) for children.
The proximal
is slightly

connection

bevelled

to accessory
INDICATIONS

for

and

flared

FOR

insertion

CHEST

and

drainage

ease

of

TUBES

of a chest

but those
of most import
spontaneous
pneumothorax,

mothorax,

to allow

tubing.

tube

are

listed

to the pulmonologist
iatrogenic
pneu-

of malignant

effusions

with

pleurodesis.
Indications
lowing:

( 1)

Spontaneous
or presence

(2)
(3)

Tension

Medicine,

Charleston.

not

in World
War II,
for acute
trauma
did

until

below,
include

PERSPECTIVE

when he described
to drain
empyemas.

was

in postoperative

Lilienthal

Indications

Hippocrates

space

the

end

ofchest
tubes;
(3) examine
individual
components
and
their optimal
characteristics;
and (4) note the spectrum
and incidence
of complications
associated
with
the

HISTORIC

needle

pleural

until
1917
postinfluenzal

plastic

be

principles
placement,

thoracostomy

the

CHARACTERISTICS

those

procedures

a hypodermic

into

problems,

place

pulmonologist
include
thoracoscopy
and pleurodesis
of a symptomatic
malignant
pleural
effusion.
The
purpose
of this paper
was to (1) review
the historic

pleural
metal

developed

inserted

purposes.
Playfair
placed
a drainage
tube
with
an
underwater
seal in 1872, and Hewitt4
described
closed
tube drainage
ofan empyema
in 1876. Due to technical

exemplify

of the chest
of nutrients.

1860s,

pneumothorax
(hemopneumotube
thoracostomy
for pneu-

or hemothorax
surgeon.
Today,

elective

care

FC.C.P1

being

Percutaneous
needle
examples
of the wider
now employed
by the

requires
invasion
and administration

M.D.,

the

physician

bronchoscopy
needle

and Complications

A. Sahn,

of diagnostic

applications

one
aspect
of the explosion.
biopsy
and thoracoscopy
are
scope
of invasive
techniques

Steven

pulmonary

Fiberoptic
transbronchial

developed

and

spectrum

to the

Management

for

tube

thoracostomy

pneumothorax
of underlying
pneumothorax

include

the

fol-

(large,
symptomatic
lung disease)
(or suspected)

latrogenic
pneumothorax
(progressive)
(4) Penetrating
chest
injuries
(5) Hemopneumothorax
in acute
trauma

258

Chest

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Copyright 1987 American College of Chest Physicians

Tubes

(Miller,

Sahn)

(6)

Patient

in

extremis

trauma
(7) Complicated

sions,
(9)
(10)

for

usually

Chylothorax
Postthoracic

of

thoracic

effusions

intractable

symptomatic

hours.

Preliminary

space

dispersion

of the

The

pleural

although
coagulopathies
weigh
on the clinicians

and platelet
judgment.

per

defects

se,

might

surfaces.

drainage

a patient
for

a large

develops
diagnosis

dyspnea
in
of reexpansion

PULMONARY

INDICATIONS

TUBE

When

minimal,

CHEST

INSERTION

pneumothorax

toms,
and
therapeutic

FOR

size,

symp-

presence
of underlying
lung disease
intervention
. Those
patients

guide
with

transient

is encountered,

symptoms,

and

less than
20 to 25 percent
increase
in the pneumothorax

evidence
of an
several
hours
can

tive

pressure

diffuse
than
fused

any

ment

treated

with

under

decompression

tension

and

tube

Smaller
tubes
(16 to 20 Fr) placed
and directed
toward
the lung apex
to evacuate

air from

expansion.
good breath

the

pleural

24 hours

and

recur.

If the

cm

20

pleural
defect
pleural

and

removed
air

H2O)

lung
be

if the

pneumothorax

persists,

application

may

aid

does

not

of suction

evacuating

air

space,
allowing
the lung to expand,
against
the parietal
pleura
and
symphysis.

from

the

sealing
the
promoting

Large
symptomatic
malignant
pleural
effusions
may
managed
by repeated
thoracocentesis
in patients
with a limited
expected
survival.
In patients
with an
expected
acostomy

survival
of several
months,
for drainage
and instillation

usually

is recommended.89

should
optimum

be

drained

slowly,

A small

inserted
and
fluid
removal.
not more

directed
Large
than

1,000

tube

tube
thorof tetracycline
(16 to 20 Fr)

posterobasally
effusions
should
ml during

for
be

the

first

24 hours.
When
drainage
is minimal
and the
roentgenogram
shows complete
lung expansion,
should
pleural

tion,

should

the

chest

tube

chest
tetra-

be instilled
through
the
space.
Following
instillabe clamped

for one

to two

of

to suction.u

tube

thor-

of effusion

and

this

the
be

complication

have

oxygen,

pleural

that
for

require

of these

drain

not

by

their

be purulent,

free-flowing

and

tubes

these

despite
not
complicated
bio-

compli-

effusions

removes

material
from the pleural
loculation,
extensive

lung

Large

defined

is

pneumonia

effusions
behave
clinically
like
be treated
in similar
fashion.

fibrogenic
and
prevents
trapped

thoracostomy
with

glucose
< 40 mg/dl,
Although
the fluid at the

may

drainage

if

a potreat-

7.20,

U/L).6

Early

and

drainage
These

are

(pH <

empyemas

potentially
rapidly

patients

empyema.

effusions

parapneumonic
and should

hyperpervolume

diuresis,

tube

Some

effusions
criteria

The
more

outcome.

of thoracocentesis

cated

reveal

ventilation.
Although
early
recognition
and

is diagnosed,

chemical
parameters
and LDH
< 1,000

to

and

immediately.

satisfying

time

Roentgenograms

leak in an acutely
involves
intravascular

to a favorable
empyema

indicated

a restrictive

effusions.

Tubes

space
pleural

ventilatory

(28 to 36 Fr) should

posteriorly
and inferiorly
and connected
to suction

be inserted

should

be

directed

or into the area of loculation

to promote
optimal
drainage.

Once
the
patient
becomes
afebnile,
pleural
space
drainage
is serous,
totaling
less than 50 m1124 hours,
and minimal
fluid remains
on chest
roentgenogram,
the tube
should
be removed
in the absence
of an
empyema

30 minutes,
to avoid
postthoracocentesis
pulmonary
edema.
Suction
may be applied
to remove
that fluid
which
does not drain spontaneously
over the next 12 to

cycline
(20 mg/kg)
chest
tube
into the

leads

fibrosis,

be

and
expan-

filling
in the ipsilateral
lung.
fluid is rich in protein
suggesting

parapneumonic

and the water

seal
be clamped
for 12 to

leak

in

allow

hours),
lung

undergone

likelihood

intubation
fatal problem,

When

demonstrates
line can not

is removed

postoperative
period,
pulmonary
edema
should

supplemental

necessary,
tentially

thoracostomy.

space

may

be

to underwater
seal
should
be sufficient

When
physical
examination
sounds,
a visceral
pleural

seen
on chest
roentgenogram,
reveals
no air leak, the tube

should

tube

complete

has

the

a simple
hydrostatic
lung.
Treatment

assessment,

pneumothorax

due

alveolar
edema

be observed.
Those
with
moderate
to severe
pain,
respiratory
distress,
or evidence
of continued
air leak
should
have tube thoracostomy
performed.
Obviously,
acute

chest

appears
to be increased
when there is chronic
collapse,
endobronchial
obstruction,
trapped
lung,
rapid
removal
of air or fluid, and increased
intrapleural
nega-

alveolar

a pneumothorax

without
over

applied
to the
and apposition

pneumothorax

The

1011

SELECTED

who

acostomy

pleural
movement.

(50 to 100 ml/24

is minimal

roentgenogram
shows
a paucity
of fluid.

When

fistula
exist

complete

patient

effu-

surgery
not

that

without

suction
is
fluid removal

the chest
sion and
do

suggest

Following
unclamping,
pleural
space to promote
when

contraindications

data
occurs

(em-

maligant

(1 1) Bronchopleural
Absolute

evidence

parapneumonic

pyema)
Pleurodesis

(8)

with

TECHNIQUE

Traditional
tion
the
second

depends
pleural

OF

CHEST

teaching
upon

intercostal

TUBE

suggests
the

that

PLACEMENT

the

site

of inser-

substance
being
removed
from
The
relatively
wide,
avascular

space

in

generally
is the recommended
ment
of a pneumothorax,
CHEST

the

midclavicular

insertion
as air rises
I 91

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Copyright 1987 American College of Chest Physicians

line

site for treatto the apical

I 2 I FEBRUARY,

1987

259

region
prime
the

of the pleural
concern,
the
midaxillary

line,

muscle

in the

surgical

scar.

tube

inserted

midaxillary

line

Loculated

fluid

tube

the

into

genogram

below

effusions

in the
should

major

be drained

intercostal

be

drained

area

on

require
more
being
drained

mothorax

or

of the

plain

roent-

or computed

air and

fluid

usually

from
a single,
appropriately
loculated
collections
of both

fluid
may
substance

--

in the

by insertion

indicated

Although

bundle

and posteriorly.

by ultrasound

guidance.

rib

by a

space

inferiorly

or as directed

can be drained
tube,
multiple

pectoralis

may

sixth

and directed
specific

tomographic

the

can be used to avoid an obvious

suggest
posterior
apical
tube
inserted,
the
tube
is directed

pleural

Free-flowing

chest

just

axilla,
Others
Once

placement.7
anteroapically.

6 If cosmetic
results
are of
to fifth intercostal
space
in

third

lung._...

placed
air and

than
one chest
tube.
The
dictates
tube size, as pneueffusions
may
be drained
by

serous

smaller
16 to 20 Fr tubes,
while
blood,
pus, or thick
fluid require
a larger
bore 28 to 36 Fr tube
to allow
adequate
drainage.
Occasionally,
as in bronchopleural
fistula,

a large

pleural

space

satisfactory

bore

tube

when
flow

may

rate

bronchopleural

fistulas

tubes

air adequately

to evacuate

and promote
unit needs

may

fistula exists
of the apparatus.
inserting

drain

two

from

the pleural

tube,

site

1. Appropriate
angle ofpenetration
into the pleural
space.

Blunt

space

may exceed

the

FIGURE
dissection

drainage

pleural
drainage
when
a persistent

as the leak

a chest

the

allow a
Some

require

pleural
symphysis.The
to be evaluated
carefully

bronchopleural
capabilities
When

adequately

a smaller
tube
might
not
to keep the lung expanded.

the

selected

dissection

clamp
has
institutions
sure on the
and
that

clamped

at the

Infiltration

and

created

pain for the

a 2 cm incision

tion,
pleural

to

union

of the

peniosteum
prevents
sterile

of the

adjacent

unnecessary
technique,

should
be made
over and parallel
the rib.
Prior
to tube
insertion,
suture
should
be placed
through

rib

to the midportion
of
a simple
mattress
the incision
for two

proximal

pleural
that

on insertion,

insertion,

when

tube

should

a pneumothorax

and

tube,

tension

securing

the

close

the

removal.

Initially,

The

incision

two

ployed
are
dissection.5
without
extends

and

prevents

techniques

for

the

lung

sharp
forced

ends

commonly

method;
and
be purchased

that
into

helps

of air.

insertion

a trocar,
a sharp-tipped
through
the distal end ofthe

with
direct
pressure
method
of insertion,
prevent
over-penetation,

suture

entry

as follows:
(1) trocar
Chest
tubes
can

rigid trocar
is sufficiently
into the incision
site and

lacerating

untied

metal
plastic

em(2) blunt
with
or

rod which
tube.
This

can be inserted
the pleural
space

it

and
a twisting
motion.
This
without
a safety
mechanism
to
has an increased
risk of
or other

intrathoracic

structures.

with

the

a Kelly

the

can be wrapped
anchoring
the

and

inserted

likelihood

positioning,

tube

is removed.

After

anteroapical

can be utilized

to prevent

the loose

ofthe

tape

anchor

the tube.

for

ends

accidental

mattress

suture

off,

tied

some

covering
the incision
with
petroto prevent
air leaks,
the application
skin and predispose
to infection,
and

thus,
is not recommended.
may be applied
to the site
Surgical

is
be

of infec-

around
the end ofthe tube and
tube to the chest
wall. Although

physicians
prefer
leum-laden
gauze
may macerate
the

it

for fluid drainage.

A
and lateral
chest roenttube position.
several
methods
of

appropriate

tube

and assure
The tube is
method,
tunnel

be directed

posterobasal

appropriate

then

Bacteniostatic

and

is applied,
Several

tag oftape

can hold

still

some

allow

blunt

of air entry
into
the
and to aid in primary

posteroanterior

confirms

After

by

forceps

With
either
subcutaneous

to lessen

wound

the

genogram

space

adhesions
entered.

decrease
the chance
space
on tube removal,

postplacement

to the

end

space.
a diagonal

reasons.
First,
when
the tube is inserted,
the ends of
the suture
can be wrapped
around
the tube and tied as
an anchoring
device
and second,
on removal
of the
applied

pleural

a finger
inserted
to lyse any
the pleural
space
has been

into
the
important

of the

the

during

replaced
the
use
of a trocar
in many
(Fig 1). Once
entry
has occurred
by presKelly clamp,
the instrument
is withdrawn

should
be cleaned
with povidone
iodine
and liberally
infiltrated
with
1 percent
xylocaine
(10 to 20 ml).
the panietal
pleura
patient.
Employing

into

by forceps

the

motion

inches
tube

ointment

covered

with

dry

to cover

the

wound

proximally,
close

without

260

to the

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Copyright 1987 American College of Chest Physicians

and

an omental
chest

disturbing
Chest

gauze.

wall
the

Tubes

site

(Miller,

and
of
Sahn)

Patient

Patient

Atrnosphere

Atmosphere
or
Su ction

TRAP

FIGURE

SEAL

WATER

BOTTLE
3. Two-bottle

BOTTLE
system

with

trap

bottle

in line

with

water

seal

bottle.

cm

2-3

important,
of six

and

sufficiently
When

strong
inserting

system
FIGURE

2. One

entry.

Once

sony

tubing

bottle

water

seal

connected
to

system

with

to drainage,

the

bed

atmospheric

pinning

sheet

the

provides

should

tion.

vent.

acces-

All

leak
Once

secured,

tubing

and

Thomas8

found

ofat

#{188}
inch

least

that glass
connectors

that

clear,

internal

connectors

should

be

tube to a drainage
device.
surgeons,
Munnell
and
plastic,

serrated

diameter

were

connectors
preferred

and

or opaque
connectors
were
avoided.
are subject
to breakage
and opaque

Glass
con-

nectors

hide

connector,
obstruct

the less likely that blood,

fluid, or tissue will
this smallest
component
ofthe
system.
Taping

the

ends

of

preventing
When
that
and

possible

the

obstruction.

connectors

to

the

LJmin20;
displays

(v

and

length

the

aids

are important

laminar

in determining

in

turbulent

flow,

and

the

indicates
the greater
tube.
In both situations,

be

prepared

drainage

exists,

complete
pleural

for

systems,

drainage

immediate

simple

resist-

suggests
an
ofY2
inch internal
flows of 50 to 60
most

suction

drainage

may

ofeffusions,

second

acting

trap
water

disease),
(Fig

connec-

or complex,

re-

water-seal
drainage
2). If a persistent
air

be

necessary

expansion
of the lung
surfaces.
A two-bottle
with

as the

below
the
withdrawal

an

constant

negative

manometer
This bottle

seal

(Fig

and would
accumulated

unregulated

vacuum

pressure

a trap

tube,

necessitate
in the

exists

and

a third

can be raised

the

of the

repeated
water
seal

source

is desired,

which

and

of the
2 to 3 cm

bottle
can be added
to the system
has an input and output
tube,
and
vent

achieve

3). Addition

recurrent
manipulation
needs
to be kept only

water
line,
as fluid

bottle.
When

to

and apposition
of the
system
is optimal
for

the first being

water

bottle
obviates
seal tube,
which

moveable
flow
Both

radius

this
is the tubing
size preferred
by
surgeons.8
Moist air in a hydropneumothorax

ir2rP/fl)9
radius
of the
=

tubing

tubing
displays
Law
(v = IT9

ance to flow. A plot of flow vs tube

exponential
relationship,
with tubes
diameter
being
capable
of handling
thoracic

larger

accidental
separation
at this site.
selecting
tubing,
it should
be remembered

gas moving
through
obeys
Poiseuilles

radius

The

prefer
a standard
length
be clear,
flexible,
and

to resist
tearing.
a chest tube, a preselected

mothorax
(no clinical
lung
may be all that is necessary

additional

SYSTEMS

selected
to attach
the chest
In a survey
of 328 thoracic

operators
should

quire a water
seal. This seal allows fluid or air to drain
without
allowing
air to be sucked
into the pleural
space.
In the case of a primary
spontaneous
pneu-

security.
DRAINAGE

most

18 Tubing

water
(Fig 4).
a central

or lowered

to

adjust
its underwater
depth.
Its depth
below the water
level determines
the negative
pressure
the system
will
generate.
When
high (50 to 60 cm) negative
pressure
is
desired
and an unregulated
wall suction
source
exists,
an inordinately
large column
of water
may be necessary to appropriately
adjust
the water manometer
vent
tube.

This

differing

problem

density
ofmercury

Fanning

equation

column

importance
tubing

of the
length
is

and

the

cury

will allow

addition

may
in

be obviated

by using

liquids

of

the manometer
bottle.
A 1-cm
is equivalent
to 13.76 cm of water;

of small,
generation

measured
ofgreater

CHEST

amounts
negative

I 91 I 2 I FEBRUARY,

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Copyright 1987 American College of Chest Physicians

of merpressures
1987

261

Patient
Adjustable
Vent

Tube

Suction

suction

when
applied

TRAP

WATER

BOTTLE

FIGURE

without

the

chambers.
three-bottle

4. Three-bottle

presence

SEAL

MANOMETER

BOTTLE

system

of awkward,

with

large

trap,

water

BOTTLE

seal,

and

manometer

adjustable

The presence
of mercury
in the third
of a
system
is safe and is not a hazard
to the
three-bottle
into a plastic

system
has been
compartmenunit which
is unbreakable,
easily

any

the

segment

problem,
respiratory

that
although
limited
by

chest
the

tube

system.

flow through
maximum

Capps

et al

two
and

L/minute;

showed

these
units
is primarily
flow rate
at the suction

conditions:
(2) suction

in Table
suction

internal
flow at

1, they found that flow through

was set at 40 L/min
decreased

resistance
of the unit
a set suction
pressure

creased.
Control
water
manometer
points

of highest

internal

are

relatively

When

and
Table

Wall

Suction

Measured

may

son

at 40 L/Min
Flow

(LIMin)

air and

tubing,

chest

compliance.
longer
the

The
tubing,

be generated

on inspiration.

could
failure

be a contributing
in patients
with
is indicated,

must
be considered.
ofgenerating
between

Sorenson

systems

of pressures
of
When
selecting

and

for ifthese
could
be

pressure

5 to 10 Lmin
and Thermovac.
are high

tion.#{176}Overall,
in Munnell
percent
of surgeons
favored
system,
with one-halfselecting

and Thomass8
a high pressure,
an Emerson

survey,
82
high flow
or similar

device.

Characteristics
Pressure
Measured

ofChest
Set
Flow

Drainage
at

20cm

H,O

Units*
Calculated

(L1Min)

Resistance

Resistance

15.0
22.8

Pleur-evac

A4005

33.5

32.7

38.0

22.5

19.7

62.7

5.8

2.3

>450

from

Capps

at 40 IJMin

(cmH,O/L/s)

34.0

*Modified

greater
seen
on

conditions
are not met, a tension
created
despite
continuous
suc-

35.5

Seal

of >20
should

pressure
pressure

34.0

Sentinel

systems

flows
care

35.5

Thoraklex

of flow
Emer-

pressure

60 cmH2O
with
a suction
system,

A4000

WS

re-

Low pressure
sys15 and 20 cm H20

Pleur-evac

Emerson

factor to continued
severe
underlying

flow

pressure
and between
the Stedman,
Gomco,

expiration,
situation

flow

In

as much
as 60 ml of air may re-enter
on inspiration.#{176} Although
not often

be exercised
to provide
a negative
than
the possible
positive
pleural

the
the

Suction

can

suction

and

capable
L/min.

be considered

1-Resistance

with

enjoy wideworkings
is

disease.

negative
include

one should
consider
the flow
systems
and employ
one with a
. Although
convenient,
these
expensive

it

quirements
tems capable

the unit
as the

high

system

backflow

When

increased.
Likewise,
fell as resistance
in-

resistance.

more

lung

set at 40
cmH,O.
As

valves
between
chambers
and
chamber
itselfwere
considered

rates
are necessary,
characteristics
ofthese
low intrinsic
resistance
units

(1) waIl suction

pressure
at - 20

closed

some
situations,
the pleural
space

source,
the unit itself contributes
significantly
to the
resistance
ofthe
system.
They examined
capabilities
of
five commonly
used
chest
drainage
units
under
the
following

Despite
their cost, they
familiarity
with
their

tube drainage
systems
have intrinsic
larger
the collection
bottle
and the

transportable,
readily
pressure
adjustable,
and permits easy access
to obtain
specimens.
These
compact
units have their own intrinsic
resistance,
as does each
ofa

tube.

an extravagance.
spread
use
and
desirable.
Like

patient.
This
talized

noted
when

vent

et al.

262

Chest

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Copyright 1987 American College of Chest Physicians

Tubes

(Miller,

Sahn)

CHEST

When

the

several

TUBE

functional

simple

integrity.

space

is not

holes

and

functioning

is suspected,

flushed

with

of a tube

the

saline

is questioned,

can be employed

of synchronous
suggest
the tube

motion

in the pleural
tube

SHOOTING

status

maneuvers

Observation

respiratory

TROUBLE

to assess

water
seal and
is still functioning

all connections

are tight.

and

occlusion

of the

tube

can

solution,

its

If the

drainage

be disconnected

in an

effort

and

generally

is

the

initial

to dislodge

approach

to

be

clamping
question

with distal suction

should
be performed.

bling
system

air
is

question
that

bottle,

it

through
clamped

which

point

tube,

the

then

connector,

water
seal
just
proximal

disappears

identifies

component

or

when

the
can

site

when
to

tube

drainage
point
in

clampedjust

of leakage;

distal
the

avulsion

(one),

and

to

and
in

an

identified

unsuccessful
agents.

tions

have

been

tube
than

through
expected,

superior
of

When
longer

the

indication

present

or the

for
tube

aware

REMOVAL

tube

thoracostomy

is nonfunctional,

be removed.
Authors
differ on the
chest tubes.627
Opinion
is divided
of clamping
prior to tube removal,

is no
it

should

methods
to remove
as to the necessity
with 75 percent
of

thoracic
surgeons
surveyed
favoring
clamping
for 12 to
24 hours
prior
to removal.8
Clamping
allows
for
identification
of persistent
air leak or re-accumulation
offluid.
We suggest
that in preparation
for removal,
bandage
should
be removed,
the site cleaned,
and
previously-tied
mattress
suture
clipped,
allowing
ends to be freed.
At the time of removal,
the
should
exhale
and perform
a Valsalva
maneuver.
tension

applied

incision

edges

and

smoothly

then
can be
Routine
wound

to the

mattress

together,

the

at end-expiration.
tied
care

to oppose
and suture

suture,

tube

The

patient
With

to hold

is removed
mattress

the
the
its

the

quickly
suture

the wound
margins.
removal
at three
to five

days
allows
for optimum
healing.
A chest
roentgenogram,
1.2 to 24 hours following
chest tube removal,
for observation
ofresidual
air or fluid is recommended.

the

rib

that

the

tortuous
with
well-described

has

emphysema
and spread

studies
of thoracostomy
tube
complications
exist;
most
reports
are anecdotal.
Milliken
et
retrospectively
analyzed
complications
in patients

were
tubes

analyzed
in a subgroup
were
placed
by blunt

expiration.
the

the

inferior

underlying
operator

tend

neushould

to become

be
more
is a
re-

effusion
or
abdominal

placement

of

complication

is

rare

segment
of the
can

over

the

ax

of lung aspirated
chest
tube.
Sub-

occur
at the site of tube
chest wall but is gener-

only a cosmetic
problem.
Prophylactic
antibiotic
administration

tube placement
requiring
tube
wounds,
Grover

Inter-

by placing

pulmonary
edema
which
follows
rapid

reported.

cutaneous
insertion

of the

is controversial.
thoracostomy
and associates1

with

chest

In a study of patients
for penetrating
chest
found that 2.6 percent

of clindamycin-treated
patients
developed
pleural
space
infection
vs 16 percent
of control
subjects.
In
contrast,

with

Neugebauer
spontaneous

receiving

et al, in a study of143 patients

pneumothorax,
found
that
those

prophylactic

antibiotics

had

a higher

compli-

cation
rate (13.8 vs 3 percent).
In the absence
of trauma
and with good aseptic
technique,
there
is no need
for
prophylactic
antibiotics
with chest
tube insertion.
REFERENCES

Few

tube
thoracostomy
over an 11-year-period.

vessels

of a peripheral
drainage
port

de-

with
lacera-

passage

its
the

age.
Unilateral
complication

been

have

occurs
more often
can rise as high as

avoiding

with

Moreover,

COMPLICATIONS

ceiving
trauma

rib and

pleural
or direct

is more

that

symphysis
stomach

on full

infarction
into
the

ally

pleural
liver, and

be avoided

intercostal

moval
of a large
Subcutaneous
tubes

lungs

can
above

bundle.

tube

of complications.

space
to the

no

to

by inadvertent

bleedings

were

pleural
symphysis
or adalso may exist following

at

reported

intercostal

artery
just

There

the diaphragm.9
This
since the diaphragm

fourth

rovascular
TUBE

attempt
Splenic,

(one).

30 cases
of
with
trocar

frequently,

with

compliance
or when
exist.9#{176}This situation

margin

liver

attributable

reported

in patients

stomach

ofthe

a variety

lung,

(1

laceration

ofthe

dissection.

directly

reports

of the

costal

lung

curve

left lobe

blunt

series

sclerosing

the

to the

of 447

complication

(two),

to the lesser

11 with

the

to occur

tube

be changed.

CHEST

lacerations

injury

Four

a technical

of 1,249
patients,
there
were
(2.4
percent),
19 associated

insertion

creased
hesions

performed.

suffered

a laceration

Of a total
empyema

likely

the spot in
of bub-

the
the

longer

diaphragm

(one),

Laceration

sequential

before
and after
Demonstration

including

no

insertion.
The literature

obstruction
with the fibrinolytic
agents
an alternative,
especially
in parapneumonic
effusions.
Ifan air leak is suspected
at a particular
point in the
system,

was
patients

deaths

obstructing
debris.
In the past,
instillation
of streptokinase
and streptodornase
was employed
successfully to open
occluded
tubes.
Today,
saline
irrigation

insertion
percent)

1 Hippocrates,

als
re-

in the setting
of acute
Technical
complications
of 447 patients
dissection
after

whose
trocar

Writings.

Hutchins
29,

BA,

ed.

In:

Great

Chicago:

books

of the

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Western

world.

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by drainage:

recovery.

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CHEST

the

treated

by aspiration

Br Med

1875;

Br Med

and

subse-

1:45
1876;

I 91 I 2 I FEBRUARY,

Downloaded from www.chestjournal.org by guest on August 2, 2009

Copyright 1987 American College of Chest Physicians

ed

255

1:317

1987

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264

Chest

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Copyright 1987 American College of Chest Physicians

Tubes

(Miller,

Sahn)

Chest tubes. Indications, technique, management and complications.

K S Miller and S A Sahn
Chest 1987;91; 258-264
DOI 10.1378/chest.91.2.258
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