Chest Tube

Thoracostomy: When to
Remove?
Heru Sutanto Koerniawan
Complication of premature tube
removal
• Pneumothorax -> Tension
• Accumulation of fluids / pus

• Increase of infection and pain

• Longer length of stay in hospital
Pleural Drain
• Fluid output less than 50 ml for pus
Fluid output less than 100 ml for clear fluid
• Studies demonstrate that tubes may safely be removed with outputs
up to 200-450 ml per day
Paydar S., Ghahramani Z., Johari G., et al. Tube Thoracostomy (Chest Tube) Removal in Traumatic Patients: What do we know? What can we do?. Bull Emerg Trauma 2015;3(2):37-40.

Younes RN, Gross JL, Aguiar S, Haddad FJ, Deheinzelin D. When to remove a chest tube? A randomized study with subsequent prospective consecutive validation. J Am Coll Surg, 2002;
195(5): 658-62.

Volume threshold for chest tube removal: A randomized controlled triavolume threshold for chest tube removal: A randomized controlled trial.

Hessami MA, Najafi F, Hatami S. Volume threshold for chest tube removal: A Randomized Controlled Trial. J Inj Violence Res. 2009; 1(1): 33–36.

Martin M, Results of a clinical practice algorithm for the management of thoracostomy tubes placed for traumatic mechanism. Springerplus. 2013: 1; 2: 642.

Baumann MH, Strange C, Heffner JE, Light R, Kirby TJ, Klein J, et al, AACP Pneumothorax Consensus Group Management of spontaneous pneumothorax: an american college of chest
physicians delphi consensus statement. Chest, 2001; 119(2): 590–602.

Laws D, Neville E, Duffy J. BTS guidelines for the insertion of a chest drain. Thorax, 2003; 58(2): 53-9.

Paramasivam E, Bodenham A, Air leaks, pneumothorax, and chest drains.cont edu anaesth crit care and pain.2008; 8(6): 204-9.
 Air Drain (Pneumothorax)
• Absence of air bubbling in chest bottle
• Clinically or radiologically expanded lung
• Less than 6 cm excursion of column of chest tube
• Absence of air leak even on hard coughing for 24 hours

Imtiaz T., Majeed TI., Raza A., et al. Is Chest Tube Clamping necessary before removal? An Experience with 2661 cases of Tube thoracotomies. Pak Armed Forces Med J 2016; 66(4):591-94
 Air Drain (Pneumothorax)
• Non resolving pneumothorax -> high volume/low pressure suction
pumps
• A high volume pump for large leak
• Performed under water seal at a level 10-20 cm H2O

Paramasivam E, Bodenham A, Air leaks, pneumothorax, and chest drains.cont edu anaesth crit care and pain.2008; 8(6): 204-9.
 Clamping or Not ?
• To stimulate the conditions of tube removal and if complication occurs
then it can simply be managed by unclamping.

• A consensus statement by ACCP

• 59% clamp prior removal
• 41% will not clamp prior removal
• BTS guidelines do not favor clamping

• No sufficient evidence that clamping a chest drain at the time its removal
is beneficial
Imtiaz T., Majeed TI., Raza A., et al. Is Chest Tube Clamping necessary before removal? An Experience with 2661 cases of Tube thoracotomies. Pak Armed Forces Med J 2016; 66(4):591-94

Baumann MH, Strange C, Heffner JE, Light R, Kirby TJ, Klein J, et al, AACP Pneumothorax Consensus Group Management of spontaneous pneumothorax: an american college of chest
physicians delphi consensus statement. Chest, 2001; 119(2): 590–602.
IS chest radiography necessary ?
• All resources confirmed the necessity of ensuring the expansion of the
lungs before removal of tube
• If respiratory condition and examination of the individual is good, an x-
ray would not be preformed before removal.
• No useful studies have shown that radiology is necessary after removal
• However it is recommended for
• Patient with artificial respiration
• No access to surgical services
• Decrease level of consciouscess
• Proposed time for radiography is at least 3 hours after tube removal
Chest tube removal for patient with
mechanical ventilation
• Keeping a chest tube under mechanical ventilation is best
• Long term indwelling chest tube -> empyema & pain

• Minimum 5-7 days after its insertion and chest X-rays is taken
• Clamping is recommended 6 hour prior removal
• It is necessary to have no tube air leak for at least 24 hours before
removal
• Clamping patients between 6 to 24 hours before removing the chest
tube. (6 hour for alert patient and 24 hour for unconscious patients)
• Chest X-ray 3 hours after removal to confirm patency
Kepustakaan
• Paydar S., Ghahramani Z., Johari G., et al. Tube Thoracostomy (Chest Tube) Removal in Traumatic Patients: What do we
know? What can we do?. Bull Emerg Trauma 2015;3(2):37-40.
• Younes RN, Gross JL, Aguiar S, Haddad FJ, Deheinzelin D. When to remove a chest tube? A randomized study with
subsequent prospective consecutive validation. J Am Coll Surg, 2002; 195(5): 658-62.
• Volume threshold for chest tube removal: A randomized controlled triavolume threshold for chest tube removal: A
randomized controlled trial.
• Hessami MA, Najafi F, Hatami S. Volume threshold for chest tube removal: A Randomized Controlled Trial. J Inj Violence
Res. 2009; 1(1): 33–36.
• Martin M, Results of a clinical practice algorithm for the management of thoracostomy tubes placed for traumatic
mechanism. Springerplus. 2013: 1; 2: 642.
• Baumann MH, Strange C, Heffner JE, Light R, Kirby TJ, Klein J, et al, AACP Pneumothorax Consensus Group Management of
spontaneous pneumothorax: an american college of chest physicians delphi consensus statement. Chest, 2001; 119(2):
590–602.
• Laws D, Neville E, Duffy J. BTS guidelines for the insertion of a chest drain. Thorax, 2003; 58(2): 53-9.
• Paramasivam E, Bodenham A, Air leaks, pneumothorax, and chest drains.cont edu anaesth crit care and pain.2008; 8(6):
204-9.
• Imtiaz T., Majeed TI., Raza A., et al. Is Chest Tube Clamping necessary before removal? An Experience with 2661 cases of
Tube thoracotomies. Pak Armed Forces Med J 2016; 66(4):591-94
• Baumann MH, Strange C, Heffner JE, Light R, Kirby TJ, Klein J, et al, AACP Pneumothorax Consensus Group Management of
spontaneous pneumothorax: an american college of chest physicians delphi consensus statement. Chest, 2001; 119(2):
590–602.