Placement and management of thoracostomy tubes
- John T Huggins, MD
John T Huggins, MD
- Associate Professor of Medicine
- Medical University of South Carolina
- Shamus Carr, MD, FACS
Shamus Carr, MD, FACS
- Assistant Professor of Surgery
- University of Maryland School of Medicine
- Section Editors
- Allan B Wolfson, MD
Allan B Wolfson, MD
- Section Editor — Adult Procedures
- Professor of Emergency Medicine
- University of Pittsburgh
- Joseph S Friedberg, MD
Joseph S Friedberg, MD
- Section Editor — Thoracic Surgery
- Charles Reid Edwards Professor of Surgery
- University of Maryland
- Anne M Stack, MD
Anne M Stack, MD
- Section Editor — Pediatric Procedures
- Associate Professor, Department of Pediatrics
- Harvard Medical School
- Eileen M Bulger, MD, FACS
Eileen M Bulger, MD, FACS
- Section Editor — Trauma Surgery
- Professor of Surgery
- University of Washington
- V Courtney Broaddus, MD
V Courtney Broaddus, MD
- Section Editor — Pleural Disease
- Professor of Medicine
- University of California San Francisco
Tube thoracostomy is a procedure in which a tube is placed through the chest wall into the pleural cavity primarily to drain air or fluid, but the tube can also be used to instill agents to induce pleurodesis or to treat empyema.
The indications, contraindications, technique, management, and complications of thoracostomy tube placement will be reviewed here. Specific medical and surgical conditions that result in the need to perform thoracostomy for pleural drainage are discussed in separate topic reviews.
Thoracostomy tube placement is indicated for the following conditions:
- Olgac G, Aydogmus U, Mulazimoglu L, Kutlu CA. Antibiotics are not needed during tube thoracostomy for spontaneous pneumothorax: an observational case study. J Cardiothorac Surg 2006; 1:43.
- LeBlanc KA, Tucker WY. Prophylactic antibiotics and closed tube thoracostomy. Surg Gynecol Obstet 1985; 160:259.
- Stone HH, Symbas PN, Hooper CA. Cefamandole for prophylaxis against infection in closed tube thoracostomy. J Trauma 1981; 21:975.
- Sanabria A, Valdivieso E, Gomez G, Echeverry G. Prophylactic antibiotics in chest trauma: a meta-analysis of high-quality studies. World J Surg 2006; 30:1843.
- Maxwell RA, Campbell DJ, Fabian TC, et al. Use of presumptive antibiotics following tube thoracostomy for traumatic hemopneumothorax in the prevention of empyema and pneumonia--a multi-center trial. J Trauma 2004; 57:742.
- Flynn PM, Shenep JL, Mao L, et al. Influence of needle gauge in Mantoux skin testing. Chest 1994; 106:1463.
- Luchette FA, Barrie PS, Oswanski MF, et al. Practice Management Guidelines for Prophylactic Antibiotic Use in Tube Thoracostomy for Traumatic Hemopneumothorax: the EAST Practice Management Guidelines Work Group. Eastern Association for Trauma. J Trauma 2000; 48:753.
- Oxman DA, Issa NC, Marty FM, et al. Postoperative antibacterial prophylaxis for the prevention of infectious complications associated with tube thoracostomy in patients undergoing elective general thoracic surgery: a double-blind, placebo-controlled, randomized trial. JAMA Surg 2013; 148:440.
- Bosman A, de Jong MB, Debeij J, et al. Systematic review and meta-analysis of antibiotic prophylaxis to prevent infections from chest drains in blunt and penetrating thoracic injuries. Br J Surg 2012; 99:506.
- Inaba K, Lustenberger T, Recinos G, et al. Does size matter? A prospective analysis of 28-32 versus 36-40 French chest tube size in trauma. J Trauma Acute Care Surg 2012; 72:422.
- Bertholet JW, Joosten JJ, Keemers-Gels ME, et al. Chest tube management following pulmonary lobectomy: change of protocol results in fewer air leaks. Interact Cardiovasc Thorac Surg 2011; 12:28.
- MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010; 65 Suppl 2:ii18.
- Havelock T, Teoh R, Laws D, et al. Pleural procedures and thoracic ultrasound: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010; 65 Suppl 2:ii61.
- Brunelli A, Salati M, Refai M, et al. Evaluation of a new chest tube removal protocol using digital air leak monitoring after lobectomy: a prospective randomised trial. Eur J Cardiothorac Surg 2010; 37:56.
- Ali HA, Lippmann M, Mundathaje U, Khaleeq G. Spontaneous hemothorax: a comprehensive review. Chest 2008; 134:1056.
- Roberts ME, Neville E, Berrisford RG, et al. Management of a malignant pleural effusion: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010; 65 Suppl 2:ii32.
- Morrison MC, Mueller PR, Lee MJ, et al. Sclerotherapy of malignant pleural effusion through sonographically placed small-bore catheters. AJR Am J Roentgenol 1992; 158:41.
- Parker LA, Charnock GC, Delany DJ. Small bore catheter drainage and sclerotherapy for malignant pleural effusions. Cancer 1989; 64:1218.
- Patz EF Jr, McAdams HP, Erasmus JJ, et al. Sclerotherapy for malignant pleural effusions: a prospective randomized trial of bleomycin vs doxycycline with small-bore catheter drainage. Chest 1998; 113:1305.
- Seaton KG, Patz EF Jr, Goodman PC. Palliative treatment of malignant pleural effusions: value of small-bore catheter thoracostomy and doxycycline sclerotherapy. AJR Am J Roentgenol 1995; 164:589.
- Rahman NM, Pepperell J, Rehal S, et al. Effect of Opioids vs NSAIDs and Larger vs Smaller Chest Tube Size on Pain Control and Pleurodesis Efficacy Among Patients With Malignant Pleural Effusion: The TIME1 Randomized Clinical Trial. JAMA 2015; 314:2641.
- Davies HE, Mishra EK, Kahan BC, et al. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion: the TIME2 randomized controlled trial. JAMA 2012; 307:2383.
- Colice GL, Curtis A, Deslauriers J, et al. Medical and surgical treatment of parapneumonic effusions : an evidence-based guideline. Chest 2000; 118:1158.
- Silverman SG, Mueller PR, Saini S, et al. Thoracic empyema: management with image-guided catheter drainage. Radiology 1988; 169:5.
- Reinhold C, Illescas FF, Atri M, Bret PM. Treatment of pleural effusions and pneumothorax with catheters placed percutaneously under imaging guidance. AJR Am J Roentgenol 1989; 152:1189.
- Merriam MA, Cronan JJ, Dorfman GS, et al. Radiographically guided percutaneous catheter drainage of pleural fluid collections. AJR Am J Roentgenol 1988; 151:1113.
- Moulton JS. Image-guided drainage techniques. Semin Respir Infect 1999; 14:59.
- Sahn SA. Use of fibrinolytic agents in the management of complicated parapneumonic effusions and empyemas. Thorax 1998; 53 Suppl 2:S65.
- Janda S, Swiston J. Intrapleural fibrinolytic therapy for treatment of adult parapneumonic effusions and empyemas: a systematic review and meta-analysis. Chest 2012; 142:401.
- Wozniak CJ, Paull DE, Moezzi JE, et al. Choice of first intervention is related to outcomes in the management of empyema. Ann Thorac Surg 2009; 87:1525.
- Ahmed AE, Yacoub TE. Empyema thoracis. Clin Med Insights Circ Respir Pulm Med 2010; 4:1.
- Symbas PN. Chest drainage tubes. Surg Clin North Am 1989; 69:41.
- Dalbec DL, Krome RL. Thoracostomy. Emerg Med Clin North Am 1986; 4:441.
- Keeling AN, Leong S, Logan PM, Lee MJ. Empyema and effusion: outcome of image-guided small-bore catheter drainage. Cardiovasc Intervent Radiol 2008; 31:135.
- Brims FJ, Lansley SM, Waterer GW, Lee YC. Empyema thoracis: new insights into an old disease. Eur Respir Rev 2010; 19:220.
- Ayed AK. Suction versus water seal after thoracoscopy for primary spontaneous pneumothorax: prospective randomized study. Ann Thorac Surg 2003; 75:1593.
- Henry M, Arnold T, Harvey J, Pleural Diseases Group, Standards of Care Committee, British Thoracic Society. BTS guidelines for the management of spontaneous pneumothorax. Thorax 2003; 58 Suppl 2:ii39.
- Lang P, Manickavasagar M, Burdett C, et al. Suction on chest drains following lung resection: evidence and practice are not aligned. Eur J Cardiothorac Surg 2016; 49:611.
- Antanavicius G, Lamb J, Papasavas P, Caushaj P. Initial chest tube management after pulmonary resection. Am Surg 2005; 71:416.
- Brunelli A, Cassivi SD, Halgren L. Risk factors for prolonged air leak after pulmonary resection. Thorac Surg Clin 2010; 20:359.
- Marshall MB, Deeb ME, Bleier JI, et al. Suction vs water seal after pulmonary resection: a randomized prospective study. Chest 2002; 121:831.
- Leo F, Duranti L, Girelli L, et al. Does external pleural suction reduce prolonged air leak after lung resection? Results from the AirINTrial after 500 randomized cases. Ann Thorac Surg 2013; 96:1234.
- Cerfolio RJ, Bass C, Katholi CR. Prospective randomized trial compares suction versus water seal for air leaks. Ann Thorac Surg 2001; 71:1613.
- Alphonso N, Tan C, Utley M, et al. A prospective randomized controlled trial of suction versus non-suction to the under-water seal drains following lung resection. Eur J Cardiothorac Surg 2005; 27:391.
- Gocyk W, Kużdżał J, Włodarczyk J, et al. Comparison of Suction Versus Nonsuction Drainage After Lung Resections: A Prospective Randomized Trial. Ann Thorac Surg 2016; 102:1119.
- Coughlin SM, Emmerton-Coughlin HM, Malthaner R. Management of chest tubes after pulmonary resection: a systematic review and meta-analysis. Can J Surg 2012; 55:264.
- Muslim M, Bilal A, Salim M, et al. Tube thorocostomy: management and outcome in patients with penetrating chest trauma. J Ayub Med Coll Abbottabad 2008; 20:108.
- Morales CH, Mejía C, Roldan LA, et al. Negative pleural suction in thoracic trauma patients: A randomized controlled trial. J Trauma Acute Care Surg 2014; 77:251.
- Aho JM, Thiels CA, El Khatib MM, et al. Needle thoracostomy: Clinical effectiveness is improved using a longer angiocatheter. J Trauma Acute Care Surg 2016; 80:272.
- Cerfolio RJ. Air leaks and the pleural space. Chest Surg Clin N Am 2002; 12:ix.
- Cerfolio RJ. Chest tube management after pulmonary resection. Chest Surg Clin N Am 2002; 12:507.
- Cerfolio RJ, Bass CS, Pask AH, Katholi CR. Predictors and treatment of persistent air leaks. Ann Thorac Surg 2002; 73:1727.
- Cerfolio RJ, Bryant AS. The management of chest tubes after pulmonary resection. Thorac Surg Clin 2010; 20:399.
- Merritt RE, Singhal S, Shrager JB. Evidence-based suggestions for management of air leaks. Thorac Surg Clin 2010; 20:435.
- Mahfood S, Hix WR, Aaron BL, et al. Reexpansion pulmonary edema. Ann Thorac Surg 1988; 45:340.
- Feller-Kopman D, Berkowitz D, Boiselle P, Ernst A. Large-volume thoracentesis and the risk of reexpansion pulmonary edema. Ann Thorac Surg 2007; 84:1656.
- Jones PW, Moyers JP, Rogers JT, et al. Ultrasound-guided thoracentesis: is it a safer method? Chest 2003; 123:418.
- Adegboye VO, Falade A, Osinusi K, Obajimi MO. Reexpansion pulmonary oedema as a complication of pleural drainage. Niger Postgrad Med J 2002; 9:214.
- American Thoracic Society. Management of malignant pleural effusions. Am J Respir Crit Care Med 2000; 162:1987.
- Wilshire CL, Louie BE, Aye RW, et al. Safety and Efficacy of Fibrinolytic Therapy in Restoring Function of an Obstructed Tunneled Pleural Catheter. Ann Am Thorac Soc 2015; 12:1317.
- Ponn RB, Silverman HJ, Federico JA. Outpatient chest tube management. Ann Thorac Surg 1997; 64:1437.
- Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest 2001; 119:590.
- Vasseur BG. A simplified technique for closing thoracostomy incisions. Ann Thorac Surg 2004; 77:1467.
- Bell RL, Ovadia P, Abdullah F, et al. Chest tube removal: end-inspiration or end-expiration? J Trauma 2001; 50:674.
- Ball CG, Lord J, Laupland KB, et al. Chest tube complications: how well are we training our residents? Can J Surg 2007; 50:450.
- Harris A, O'Driscoll BR, Turkington PM. Survey of major complications of intercostal chest drain insertion in the UK. Postgrad Med J 2010; 86:68.
- Daly RC, Mucha P, Pairolero PC, Farnell MB. The risk of percutaneous chest tube thoracostomy for blunt thoracic trauma. Ann Emerg Med 1985; 14:865.
- Helling TS, Gyles NR 3rd, Eisenstein CL, Soracco CA. Complications following blunt and penetrating injuries in 216 victims of chest trauma requiring tube thoracostomy. J Trauma 1989; 29:1367.
- Menger R, Telford G, Kim P, et al. Complications following thoracic trauma managed with tube thoracostomy. Injury 2012; 43:46.
- Collop NA, Kim S, Sahn SA. Analysis of tube thoracostomy performed by pulmonologists at a teaching hospital. Chest 1997; 112:709.
- Muthuswamy P, Samuel J, Mizock B, Dunne P. Recurrent massive bleeding from an intercostal artery aneurysm through an empyema chest tube. Chest 1993; 104:637.
- Kollef MH, Dothager DW. Reversible cardiogenic shock due to chest tube compression of the right ventricle. Chest 1991; 99:976.
- Stark DD, Federle MP, Goodman PC. CT and radiographic assessment of tube thoracostomy. AJR Am J Roentgenol 1983; 141:253.
- Webb WR, LaBerge JM. Radiographic recognition of chest tube malposition in the major fissure. Chest 1984; 85:81.
- Lim KE, Tai SC, Chan CY, et al. Diagnosis of malpositioned chest tubes after emergency tube thoracostomy: is computed tomography more accurate than chest radiograph? Clin Imaging 2005; 29:401.
- Ahmad T, Ahmed SW, Soomro NH, Sheikh KA. Thoracoscopic evacuation of retained post-traumatic hemothorax. J Coll Physicians Surg Pak 2013; 23:234.
- Velmahos GC, Demetriades D, Chan L, et al. Predicting the need for thoracoscopic evacuation of residual traumatic hemothorax: chest radiograph is insufficient. J Trauma 1999; 46:65.
- Kong VY, Sartorius B, Oosthuizen GV, Clarke DL. Prophylactic antibiotics for tube thoracostomy may not be appropriate in the developing world setting. Injury 2015; 46:814.
- Kopec SE, Conlan AA, Irwin RS. Perforation of the right ventricle: a complication of blind placement of a chest tube into the postpneumonectomy space. Chest 1998; 114:1213.
- Meisel S, Ram Z, Priel I, et al. Another complication of thoracostomy--perforation of the right atrium. Chest 1990; 98:772.
- Rashid MA, Wikström T, Ortenwall P. Mediastinal perforation and contralateral hemothorax by a chest tube. Thorac Cardiovasc Surg 1998; 46:375.
- Gerard PS, Kaldawi E, Litani V, et al. Right-sided pneumothorax as a result of a left-sided chest tube. Chest 1993; 103:1602.
- Resnick DK. Delayed pulmonary perforation. A rare complication of tube thoracostomy. Chest 1993; 103:311.
- Fraser RS. Lung perforation complicating tube thoracostomy: pathologic description of three cases. Hum Pathol 1988; 19:518.
- Antibiotic prophylaxis
- Tube selection
- - General considerations
- - Pneumothorax
- - Tension pneumothorax
- - Hemothorax
- - Malignant effusion
- - Parapneumonic effusion
- - Empyema
- Insertion site
- Drainage system
- - Level of suction
- Role of ultrasound or other imaging
- Tube thoracostomy
- - Standard technique
- - Seldinger technique
- Needle thoracostomy
- MANAGEMENT OF THORACOSTOMY TUBES
- Assessing air leak
- Managing initial drainage
- Troubleshooting thoracostomy tubes
- Management during thoracic procedures
- Outpatient management
- - Criteria: Pneumothorax
- - Criteria: Effusion
- - Removal technique
- MORBIDITY AND MORTALITY
- Chest tube malposition
- Organ injury
- Reexpansion pulmonary edema
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS