INTRODUCTION — Thoracostomy tubes or catheters placed in hospitalized patients require daily assessment to determine the presence of air leak, provide ongoing adjustment of suction level, and to monitor for malfunction, which may include obstruction, malposition, or disconnection.
For the purposes or our discussion, we use "thoracostomy tube" to refer to traditional tubes, which are clear with longitudinal markers and are generally stiffer and with larger diameter thoracostomy tubes (≥16 French [Fr]) requiring a surgical incision for placement (ie, "surgically placed thoracostomy tubes"). We use "thoracostomy catheter" to refer to smaller diameter thoracostomy tubes (≤14 Fr) and more flexible opaque specialty devices (eg, pigtail). Thoracostomy catheters can be placed over a wire using a Seldinger technique (ie, "percutaneously placed thoracotomy tubes") .
The management of thoracostomy tubes or catheters is reviewed. Specific medical and surgical conditions that result in the need to perform thoracostomy for pleural drainage, and techniques for placement are reviewed separately and discussed in more detail in separate topic reviews. (See "Thoracostomy tubes and catheters: Indications and tube selection in adults and children" and "Thoracostomy tubes and catheters: Placement techniques and complications".)
DRAINAGE SYSTEMS — Following placement of a thoracostomy tube or catheter, wet or dry suction control, closed-drainage systems are typically used, and each is effective. The configuration and function of a typical wet-control, closed-drainage system (eg, Pleur-evac) is detailed in the figure (figure 1A-B). Other closed-suction systems are available that allow the patient to be mobile (figure 2). Ad hoc ("improvised") systems can be used as a temporary measure, with sterile water in a small container to mimic a water seal, without suction . It is important that the fluid container be placed below the catheter to avoid inadvertent suction of fluid into the pleural space.
Thoracostomy tube or catheter drainage systems usually incorporate a pressure release valve that rapidly equilibrates the collection chamber pressure with atmospheric pressure without disconnecting the suction tubing. This feature can be used if the patient develops chest pain as a result of too rapid an evacuation of large pneumothoraces or pleural effusions. (See "Thoracostomy tubes and catheters: Placement techniques and complications", section on 'Re-expansion pulmonary edema'.)
Level of ongoing suction — Commercial closed-drainage systems typically allow the suction level to be adjusted between 0 and -40 cm of water. The typical level of continuous suction used in the clinical setting is -10 to -20 cm H2O of water (adult and pediatric populations), which can be adjusted upward or downward if there is failure to drain or improvement respectively.
The level of continuous suction and its use depends upon the indication. Suggested suction levels are given below:
●For spontaneous air leaks, maintaining the least amount of suction (including none [ie, water seal]) to maintain full expansion of the lung is appropriate. For incomplete resolution of the pneumothorax, suction may be added or increased, as needed, as determined by the chest radiograph. A persistent air leak without complete re-expansion is the usual reason for applying (or increasing) suction .
●When the thoracostomy tube or catheter is placed for fluid drainage, the level of suction should be increased, as indicated, from the initial setting (eg, -20 cm of water) with the goal of achieving full lung expansion as determined by the chest radiograph. Sometimes the lung is trapped, and if this occurs, increasing suction can be detrimental. If after fluid has been fully drained there is concern for a pneumothorax but no air leak, increasing the level of suction is not warranted. (See 'Air leak monitor' below.)
●Following lung resection surgery, whether ongoing suction applied to the thoracostomy tube improves or worsens pleural leaks is controversial. This issue is discussed separately. (See "Overview of pulmonary resection", section on 'Chest tube placement and management'.)
Air leak monitor — The number of columns (eg, 1 to 7) that are bubbling in the air leak gauge (figure 1A-B) of a wet suction-controlled, closed-drainage system provides a semiquantitative measure of the severity of the leak. It does not indicate flow in any precise manner but can provide an indication of any day-to-day increases or decreases in the degree of air leak. If an air leak gauge is not available, then one can assess for continuous versus intermittent air leaks. If the lung is fully inflated, the suction can be adjusted to the lowest amount needed to maintain lung inflation, although care should be taken with continuous air leaks (ideally with the elimination of suction).
Pleural drainage systems with electronic measurement and display (ie, digital pleural drainage systems) represent an advancement in drainage systems and may simplify assessment of air leaks [4-6]. These provide real-time objective measurements and digitally track fluid output and the rate of air leak. The precise point when the air leak resolves can easily be identified with the digital readout, helping to reduce the possibility of missing small leaks and decreasing unexpected pneumothorax after removal of the tube or catheter.
MANAGEMENT OF THORACOSTOMY TUBES — After a thoracostomy tube or catheter has been inserted, the management and removal of the tube is the same for adults and pediatric patients as described below.
Classifying air leak — The presence of air leak should be assessed periodically to determine whether the tube can be removed. The integrity of the tubing and drainage device should be inspected to ensure that any air leak that is present is from the lung. For patients who are admitted to the hospital, daily assessment for air leak is usually sufficient. (See 'Removal' below.)
Qualitatively, air leaks are classified as follows with increasing severity [7-9]:
●FE1 to FE7: Forced expiratory (FE), only noted with coughing or Valsalva
●E1 to E7: Expiratory (E), alveolar-pleural fistulas
●I1 to I7: Inspiratory (I), ventilated patient, bronchopleural fistula, alveolar-pleural fistula
●C1 to C7: Continuous (C), ventilated patient, true bronchopleural fistula
Troubleshooting thoracostomy tubes/catheters — If a closed-suction system becomes disconnected, the tube should be cleaned with an antiseptic (eg, alcohol, povidone iodine) and the tubing reconnected. If a new closed-suction apparatus is immediately available, the new one should be connected and the old one discarded. In a patient who has an air leak, the thoracostomy or catheter tube should not be clamped, because doing so can lead to tension pneumothorax.
If the thoracostomy tube or catheter is no longer draining and there is a suspicion that it is full of clot or debris, the tube can be stripped or cleared of obstruction by other maneuvers. These manipulations should only be performed by an experienced clinician, typically the clinician who places and manages the tube. Care should be taken to avoid dislodging the tube during these attempts. A tube that has become partially dislodged and exposed to the external environment should not be reinserted.
●To strip a thoracostomy tube, hold the tube near its insertion site with the nondominant hand, compress the tube between the first and second fingers of the dominant hand, and gently pull toward the drainage system. Because there can be a significant amount of friction between fingers and tube, it is helpful to apply a lubricant (eg, soap, water-based lubricant) to the tube prior to stripping. One danger of stripping a thoracostomy tube is the potential for creating high negative pressure within the pleural cavity. Therefore, this procedure should only be performed if the tube is absolutely known to be in the correct position (ie, not adjacent to mediastinal structures).
●If stripping a thoracostomy tube once or twice does not clear the tube and reestablish respiratory variation in the drainage system, other maneuvers can be performed under sterile conditions. These include twisting the tube 360 degrees, pulling the tube out 1 to 2 cm, passing a sterile endotracheal tube suction catheter, attempting to clear with a Fogarty balloon catheter, or injecting a small volume of sterile saline with a few drops of povidone-iodine.
For small thoracostomy tubes or catheters (<10 French), care should be taken to ensure the tube does not become nonfunctional due to clot or fibrinous debris. If the catheter does become obstructed, irrigation can be attempted by injecting a small amount of saline (5 to 10 mL) in a sterile fashion. As with thoracostomy tubes, obstructed catheters should only be managed by surgeons or other clinicians experienced with their assessment and management. Care should be taken to not cause inadvertent pulmonary complications (eg, pneumothorax) with large amounts or vigorous installation of fluids under high pressure. In small children and infants (term or premature), routine flushing is generally not performed. If a catheter becomes nonfunctional and is not needed, it should be removed. However, if necessary, a small amount of fluid (5 to 10 mL) can be used, or the use of fibrinolytic agents can be considered instead. To irrigate a catheter:
●Ideally, a three-way stopcock should be positioned between the thoracostomy catheter and drainage tube. This allows saline irrigation without disrupting the connection of the catheter and the drainage tube. In this case, clean the three-way stopcock hub with alcohol or povidone iodine-based swab, attach the syringe, turn the stopcock to allow flow from the syringe into the thoracostomy tube to clear the blockage, and quickly inject. If the blockage is cleared, return the stopcock to allow inline flow from the thoracostomy tube to the drainage tube. Otherwise repeat the saline injection until the blockage is cleared.
●If a three-way stopcock is not available, the thoracostomy catheter should be clamped to avoid entraining air into the chest when the tubes are disconnected. Once the thoracostomy catheter is manually occluded, clean the connection between the thoracostomy catheter and drainage catheter with alcohol or a povidone-iodine based swab prior to inserting the saline-filled syringe. Unclamp the thoracostomy catheter, insert the syringe, and inject the saline. If the obstruction is cleared, re-clamp the catheter and reattach it to the drainage tube.
If all the maneuvers described above fail to resolve the problem and the patient still has indications for thoracostomy, then a new tube should be placed. The nonfunctioning tube should be removed only after the correct placement of the new tube is confirmed and it is functioning properly.
Management during thoracic procedures — Whether to keep the current thoracostomy tube in place or remove it prior to a planned thoracic surgical procedure (thoracotomy, video-assisted thoracoscopic surgery [VATS]) must be individualized depending upon the nature of the surgery, the presence or absence of air leak, and the type of anesthesia (eg, one-lung ventilation). In general, the tube is removed just before surgery during the course of preparation and draping, and a new tube is placed through a separate site after the procedure is completed. For VATS, the tube insertion site may be used to introduce the thoracoscope.
In other situations, the thoracostomy tube or catheter may need to be maintained. As an example, in the patient with a large air leak, removal of the tube during preparation for surgery could lead to tension pneumothorax. Under this circumstance, the tube or catheter is maintained until the chest has been entered, and then the tube is removed. (See "Lung isolation techniques" and "One lung ventilation: General principles".)
Outpatient management — Outpatient management of thoracostomy tubes in adults is safe and cost effective. In one study, only 4 percent of patients were readmitted for tube failure or complication (eg, recurrent pneumothorax) . In the pediatric population, outpatient management may be an option for the older adolescent patients with stable, nonprogressive spontaneous or simple pneumothorax. Most younger pediatric patients who need thoracostomy tube or catheter placement should be admitted to the hospital for observation. Indications for and outcomes of specific pulmonary conditions are discussed in separate topic reviews. (See "Thoracostomy tubes and catheters: Indications and tube selection in adults and children", section on 'Indications'.)
REMOVAL — To minimize the risk of infectious complications, the tube should be removed as soon as it is safe to do so. The following criteria should be met prior to thoracostomy tube or catheter removal.
●The lung is fully expanded.
●No visible air leak is present, and air does not accumulate when suction is removed. If there is any question whether a leak has completely sealed, some clinicians clamp the tube in addition to water seal, but this is usually not necessary . There is varying practice on the duration of water seal prior to tube removal. Proponents suggest that clamping will identify intermittent air leaks that would not otherwise be detected. If the tube is clamped, the patient should be under the direct care of the supervising clinician and the patient monitored closely for clinical signs of pneumothorax/effusion, and if the patient has any hemodynamic or respiratory difficulty during clamping, the tube should be unclamped immediately. Imaging (plain film, ultrasound) can be obtained to identify any possible air re-accumulation that may or may not be clinically apparent.
●Whether to maintain a thoracostomy tube or catheter in a patient on mechanical ventilation who has developed a pneumothorax is controversial. Proponents believe it should remain in place as long as the patient requires mechanical ventilation, even when no air leak is present, while others maintain that prolonged tube placement is not necessary and increases the risk of infection. While there are no studies to guide tube or catheter management in this setting, and opinion is divided, our preference is to remove the tube as soon as it is safe. (See "Diagnosis, management, and prevention of pulmonary barotrauma during invasive mechanical ventilation in adults".)
●The lung is adequately expanded. With empyema, there may still be pockets of fluid remaining. If the majority has been drained, and the patient is doing well (afebrile, no leukocytosis, and returned appetite), and pleural-pleural apposition has occurred as documented by radiographic imaging, the remainder of the pleural abnormality is likely to resolve on antibiotics alone.
●Daily fluid output is less than 100 to 300 mL/day in adults, and likely less for the pediatric population; however, there are no studies upon which to base a specific threshold . The threshold is individualized depending upon the indication for the insertion and patient size (eg, weight and height [or length]). Unfortunately, there are no nomograms that address fluid output for a given patient size.
Removal technique — If the removal criteria above are met, the suction is eliminated. Prior to removing the thoracostomy tube or catheter, the likelihood of developing respiratory distress due to recurrent pneumothorax should be considered, and the patient should be monitored accordingly after removal.
In preparation for removal of a thoracostomy tube or catheter, it is important to have all supplies in the room and readily available. Some advocate placing petroleum gauze on the tube or catheter site under a dry sterile dressing . However, this has never been shown to decrease the risk of post-pull pneumothorax. There is also the theoretical risk of delayed wound healing at the insertion site.
While some advocate pulling the thoracostomy tube or catheter at end-inspiration, others advocate pulling at end-expiration. A small study comparing these two techniques did not show a difference in post-pull pneumothorax . Either way, prior to removing the tube, the technique that will be used should be explained to the patient. The removal of the tube is invariably painful and can cause a sudden gasp/inspiration if the patient is caught off guard. The patient should rehearse this several times prior to the actual tube removal. To remove the tube or catheter, hold the dressing near its insertion site with the nondominant hand, ask the patient to perform the planned technique, and verbally reinforce it. Ensure that the sutures that secured the tube in place are removed prior to attempting to remove the tube. At the appointed time, remove the tube or catheter quickly with the dominant hand while placing a dry sterile dressing with or without petroleum gauze. During placement, some operators provide a suture at the exit site to tie at the time of tube removal. If this approach is used, then two operators may be preferred at the time of removal to avoid air entrainment during the process: one to pull the tube or catheter and occlude the site with a dressing and the other to tie the suture. Once the tube or catheter has been removed, secure the dressing with tape.
Obtain a chest radiograph to evaluate for recurrence of pneumothorax and/or re-accumulation of fluid. An additional chest radiograph the next day is not mandatory and should only be ordered if clinically indicated.
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Pneumothorax (collapsed lung) (The Basics)")
PATIENT PERSPECTIVE TOPIC — Patient perspectives are provided for selected disorders to help clinicians better understand the patient experience and patient concerns. These narratives may offer insights into patient values and preferences not included in other UpToDate topics. (See "Patient perspective: Lymphangioleiomyomatosis (LAM)".)
SUMMARY AND RECOMMENDATIONS
●Thoracostomy tubes and catheters – Thoracostomy tubes or catheters in hospitalized patients require daily assessment to determine the presence of air leak, to provide adjustments of suction level, and to monitor for malfunction, which may include obstruction, malposition, or disconnection. For adult patients who have a chronic indication for a thoracostomy tube or catheter, outpatient management is safe and cost effective. (See 'Introduction' above.)
●Monitoring suction level – The level of continuous suction should be evaluated daily, with adjustments made upward or downward depending on clinical progress as judged by chest radiography. (See 'Level of ongoing suction' above.)
●Monitoring for air leak – The level of air leak should be evaluated daily and classified. Pleural drainage systems with electronic measurement and display (ie, digital pleural drainage systems) may simplify assessment of air leaks and may help reduce missing small air leaks and decrease the occurrence of unexpected pneumothorax after thoracostomy tube or catheter removal. (See 'Air leak monitor' above and 'Classifying air leak' above.)
●Perioperative management – Whether to keep the current thoracostomy tube or catheter in place or remove it prior to a planned thoracic surgical procedure (thoracotomy, video-assisted thoracoscopic surgery [VATS]) is individualized depending upon the nature of the surgery, the presence or absence of air leak, and the type of anesthesia (eg, one-lung ventilation). (See 'Management during thoracic procedures' above.)
●Removal – Thoracostomy tubes or catheters are removed as soon as it is safe to do so, which helps to minimize the risk of infectious complications. For pneumothorax, thoracostomy tube removal is indicated once the lung is fully expanded and no visible air leak is present. For pleural effusion, thoracostomy tubes or catheters are removed once the daily fluid output has declined. Although there are no studies to define a specific threshold, we use <100 to 300 mL/day for adults. The level in infants and children is individualized. The technique for thoracostomy tube or catheter removal is discussed above. (See 'Removal' above and 'Removal technique' above.)
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