Background

Tube thoracostomy is often used to treat pleural effusion, pneumothorax, hemothorax, hemopneumothorax, and empyema.^[1]The use of chest tubes was described as long ago as the time of Hippocrates (c. 460 BCE), when metal tubes were placed to treat empyema.^{[2, 3]}Playfair, treating a child with empyema thoracis in 1873, is credited with being the first physician to use a water-sealed chest drainage system. Chest-tube placement techniques evolved and were perfected during the 1918 flu epidemic and subsequently in the management of combat injuries during World War II.^[3]

Physiologically, a potential space exists between the parietal pleura (abutting chest wall) and the visceral pleura (abutting lung parenchyma), which normally contains less than 25 mL of pleural fluid. The presence of excess fluid, air, blood, chyle, or pus in this pleural space results in displacement of pulmonary volume, which disrupts gas exchange. Prompt drainage of this abnormal intrapleural collection is required to restore normal pulmonary mechanics.

In other scenarios, indwelling chest tubes may be placed for postoperative management of patients after lung resections in order to facilitate creation of space for lung reexpansion. Because chest tubes are used to treat patients with both medical and surgical diagnoses, physicians should be familiar with the appropriate management of patients with these drains.

Despite the widespread use of tube thoracostomy, management of patients with chest tubes remains subjective.^[4]There remains a need for more high-quality prospective data to guide postplacement management of chest tubes, and management has been driven mainly by anecdotal experience and institutional protocols.^{[5, 6]} Improper management of inserted chest tubes results in premature or delayed removal, both of which may be associated with increased morbidity, hospital stay, and costs.

This article discusses the essential and pragmatic concepts of postplacement management of patients with chest tubes. For details on the technique for chest-tube placement, see Tube Thoracostomy.^[7]

Indications

Indications for chest drains include the following:

Pneumothorax (spontaneous, tension, iatrogenic, traumatic)
Pleural collection - Pus ( empyema), blood ( hemothorax), chyle ( chylothorax)
Malignant effusions (pleurodesis)
Postoperative
Thoracotomy
Video-assisted thoracoscopic surgery (VATS)

Contraindications

The need for emergency thoracotomy is an absolute contraindication for tube thoracostomy.

Relative contraindications include the following:

Coagulopathy
Pulmonary bullae
Pulmonary, pleural, or thoracic adhesions
Pulmonary abscess
Loculated pleural effusion or empyema
Skin infection at the chest-tube insertion site

Periprocedure

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Media Gallery

The underwater drainage bottle.
The trap bottle.
Chest drain multipurpose unit.
The suction bottle.
Chest drain multipurpose model Oasis (Atrium Medical Corporation, Hudson, NH).

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Table 1. Troubleshooting Chest Drain Management^[34, 35]

Table 1. Troubleshooting Chest Drain Management ^{[34, 35]}

Problem	Mechanism	Fix
Column is not oscillating	Blocked tubing	Squeeze, milk, or flush the drainage tubing; restoration of patency is confirmed by a respiration-related swing in the draining tube
Tubes dislodged/disconnected	Dislodged tube	Check connections and reposition under sterile technique; use new entry site if completely dislodged
Leak around the tube	Partial block in the draining system	Remove all blocks from the draining system; if leak persists, place a single nonabsorbable suture to close the leak
Underwater seal bottle/drainage system broken	N/A	Clamp chest tube, replace immediately with a fresh bottle/drainage system, and recreate the underwater seal
Blocked tube due to poor positioning	Tube gets trapped in the major fissure of the lung	Withdraw tube and reinsert at a different location.
Cardiac dysrhythmia	Tube is abutting the mediastinum	Try withdrawing the tube by 1-3 cm; if this is not helpful, remove the old tube and replace at a new entry site
Persistent pneumothorax	Obstructions or leaks in the drainage system	If no leak or obstruction is found, apply suction of up to –20 cm H₂O
Failure of the lung to fully reexpand	Bronchial plug Fibrinous peel over the lung	Fiberoptic bronchoscopy Decortication
Infection	Rare; reflects breaks in sterility and incorrect management	Antibiotics

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Author

Pranit Chotai, MD Assistant Professor of Surgery, Division of Transplant Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and UH Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine

Pranit Chotai, MD is a member of the following medical societies: American College of Surgeons, American Pediatric Surgical Association, American Society of Transplant Surgeons, Americas Hernia Society, Association for Academic Surgery, Pediatric Trauma Society, Society of Asian Academic Surgeons, Tennessee Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Alexander Feliz, MD Assistant Professor of Surgery and Pediatrics, Associate Program Director, Pediatric Surgery Residency, Program Director, Critical Care Fellowship, Director, Minimally Invasive Surgery Fellowship, University of Tennessee Health Science Center College of Medicine; Associate Medical Director, Trauma Services, Le Bonheur Children’s Hospital

Alexander Feliz, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for Academic Surgery, International Pediatric Endosurgery Group, Society of Black Academic Surgeons, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Eunice Yuee-Dean Huang, MD, MS, FACS, FAAP Associate Professor of Surgery and Pediatrics, University of Tennessee Health Science Center College of Medicine; Clinical Research Fellowship Director for Pediatric Surgery, Chief Research Biomedical Informatics Officer, Biomedical Informatics Core, Children’s Foundation Research Institute, LeBonheur Children’s Hospital

Eunice Yuee-Dean Huang, MD, MS, FACS, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Medical Informatics Association, American Pediatric Surgical Association, Association for Academic Surgery, Association of Women Surgeons, Pacific Association of Pediatric Surgery, Southern Surgical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD, FACP, FCCP Geri and Richard Brawerman Chair in Pulmonary and Critical Care Medicine, Professor and Executive Vice Chairman, Department of Medicine, Medical Director, Women's Guild Lung Institute, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD, FACP, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Thoracic Society

Disclosure: Nothing to disclose.

Additional Contributors

Michael R Filbin, MD, FACEP Clinical Instructor, Department of Emergency Medicine, Massachusetts General Hospital

Michael R Filbin, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Clement Shirodkar Rajan, MBBS, MS, MNAMS, FRCS(Glasg), DHHM Medical Director and Consultant General Surgeon, Mallya Hospital, India

Clement Shirodkar Rajan, MBBS, MS, MNAMS, FRCS(Glasg), DHHM is a member of the following medical societies: International College of Surgeons, Association of Surgeons of India, National Academy of Medical Sciences (India), Hernia Society of India, Asia Pacific Hernia Society, Indian Association of Gastrointestinal Endo Surgeons

Disclosure: Nothing to disclose.