Fig. 31.5  Cook® Thal-Quick chest tube. Courtesy of Cook Medical

commercially available large, straight (up to 32 Fr) chest tubes (Cook® Thal-Quick) that can be inserted through the percutaneous approach (Fig. 31.5); however, larger tubes (above 16–18 Fr) are usually more challenging to place via this technique because of the signifcant number of dilations needed for insertion.

Complications of Chest Tube

Placement

The most reported complications of chest tube placement include bleeding, skin and pleural infections, pneumothorax, organ injury (lung, heart, liver, spleen, etc.), tube malposition and dislodgement, re-expansion pulmonary edema, pain requiring chest tube removal, and tumor seeding of the tract. The development of complications depends on operator training level, whether it is an emergent or elective procedure, and the complexity of the pleural space, but are reported to occur in 1% to 6% of cases [7].

Special Considerations

Pneumothorax

CT scan of the chest is the gold standard for estimating the size of pneumothorax and differentiating this from large bullae and emphysema

in patients with underlying lung disease. The cutoff of >2 cm between the lung edge and the chest wall at the level of the hilum is used to defne a large pneumothorax based on the 2010 British Thoracic Society (BTS) guidelines, [5] whereas the American College of Chest Physicians (ACCP) uses 3 cm from the apex to the thoracic cupola for this defnition [8]. The Light’s index utilizes the length of the lung (L) and the length of the hemithorax (H) at the hilum to calculate the percentage of pneumothorax based on the formula (1 − L3/H3) × 100 (Fig. 31.6) [9]. While recent evidence suggests that patients with a moderate to large primary spontaneous pneumothorax can be effectively managed at home, [10, 11] patients with secondary spontaneous pneumothorax require close medical attention. Unstable patients, regardless of the size of the pneumothorax, require chest tube placement.

Empyema

Pleural uid should be sampled when there is suspicion of a pleural infection and a chest tube should be inserted in cases of complicated effusions and empyema, with the goal being prompt evacuation and complete drainage of infected pleural uid. If imaging suggests residual pleuraluid without suffcient drainage from the chest tube, fbrinolytics are often administered to facilitate drainage. Thoracic surgery should be consulted for consideration of surgical intervention in cases of incomplete drainage of the pleural space despite fbrinolytics. There is also evidence that medical thoracoscopy is safe and may shorten the length of the hospital stay in a select group of patients with empyema [12].

Hemothorax

Hemothorax is the presence of blood in the pleural space defned by a pleural uid hematocrit of at least 50% blood hematocrit. It is usually secondary to trauma or iatrogenic causes. A chest tube is placed to evacuate the pleural space and

Fig. 31.6  British Thoracic Society, American College of Chest Physicians and Light Index for measurement of pneumothorax.

Illustration by Faris Kudrath

American college of chest physicians:

Apex-cupola distance

British thoracic society:

Interpleural distance at hilum

Light index:

L: Diameter of collapsed lung

H: Diameter of inner hemithorax at hilum Estimated pneumothorax size = (1-L3/H3)×100

estimate the rate of bleeding to determine the need for additional interventions such as surgery or arterial embolization. Historically, larger chest tubes were recommended for hemothorax given concern for clogging of smaller tubes with blood clots. More recent literature suggests that there is no signifcant difference [13, 14] in chest tube failure rates between smaller pigtail catheters and larger bore chest tubes in the management of hemothorax, but the decision should still be made on a case-by-case basis.

Malignant Pleural Efusion

Malignant pleural effusion (MPE) is a common clinical problem and can complicate almost any malignancy. Definitive management for a symptomatic MPE is recommended for recurrence after initial drainage [15–17]. Chest tubes are frequently part of the management plan and are placed during thoracoscopic and non-­thoracoscopic pleurodesis procedures. IPCs are another option for definitive

MPE management and will be discussed in further detail later in the chapter.

Chest Tube Size Considerations

The TIME-1 (First Therapeutic Intervention in Malignant pleural Effusion) trial evaluated the effect of chest tube size on pleurodesis success and pleural pain in patients with MPE undergoing both thoracoscopic and non-thoracoscopic pleurodesis procedures. One-third of the patients (114 out of 320) were randomized to 12 versus 24 Fr tube placement for non-thoracoscopic pleurodesis. The trial showed that smaller bore chest tubes may be inferior to larger chest tubes for pleurodesis, although the study was underpowered for this outcome with a 15% non-­ inferiority margin. There was a statistically signifcant difference in pain between the two groups with less pain experienced by those with smaller chest tubes. This difference, however, may not correlate with actual clinical beneft given the small absolute difference in pain

between the two groups [18]. A more recent 2018 meta-analysis of randomized controlled trials evaluating the impact of chest tube size on pleurodesis effcacy in MPE showed no signifcant difference between large (>14 Fr) and small (≤14 Fr) bore chest tubes [11].

A systematic review and meta-analysis of 11 studies by Chang and colleagues demonstrated small-bore chest tubes were as effcacious as large-bore chest tubes for the management of spontaneous pneumothorax with signifcantly lower complication rates (for secondary spontaneous pneumothorax), shorter duration of ­drainage, and hospital stay with small bore chest tube use [19]. Bauman et al. published their 7-year experience with 14 Fr pigtail catheters versus 32–40 Fr chest tubes in patients with traumatic hemothorax and hemopneumothorax in 2018, which showed no difference in chest tube failure rates [14]. This study was followed by a randomized controlled trial by the same group, published in 2021, which confrmed no signifcant difference in the failure rates between 14-Fr and 28–32 Fr chest tubes. Patients also reported a better experience during placement of smaller chest tubes [13]. The MIST-1 (Multi-center Intrapleural Streptokinase) trial compared intrapleural streptokinase to placebo for the treatment of pleural infection. Other measured outcomes included change in lung function at three months, chest radiograph improvement, hospital length of stay, and difference in pain between groups with various sized chest tubes. Smaller, guidewireinserted chest tubes were found to cause less pain and discomfort than blunt-dissection-inserted larger tubes and there was no difference in therapeutic outcomes [20]. Based on current literature, there is no solid evidence to demonstrate the superiority of larger bore chest tubes over smallbore chest tubes in the routine treatment of empyema, pneumothorax, or hemothorax.

Complications and Troubleshooting

Chest Tubes

Small-bore chest tubes have a greater tendency to become occluded and saline ushes every 6–12 h

to ensure patency is recommended [7]. The absence of respiratory variation suggests kinking or chest tube occlusion. If a persistent air leak is present, it is important to remove the entire dressing and examine the chest tube insertion site to ensure that one of the side holes is not located outside of the pleural cavity, giving a false impression of a continued bronchopleural or alveolar-pleural fstula. A simple test includes clamping the chest tube close to the skin to ensure that the air leak is not coming from the drainage system. If it continues after clamping, then it does not originate in the pleural cavity.

Assessment of the readiness for chest tube removal depends on the etiology, either pneumothorax or pleural effusion. There should be evidence of clinical and radiographic improvement in pneumothorax with the absence of a visible air leak. Once these criteria are met, the tube can be transitioned from suction to “water seal” for 4 to 24 h. If no signifcant change in clinical status or chest imaging occurs, the tube can be clamped for an additional 4 to 24 h (based on clinical judgment) and then removed after repeat chest imaging. Complete pleural apposition is the desired outcome, but this is not always possible, especially in patients with signifcant underlying lung disease. A small residual pneumothorax may be accepted if stability is achieved. In general, chest tubes are maintained for the duration of mechanical ventilation in patients receiving positive pressure ventilation. Clinical and radiographic improvement (chest x-ray and bedside ultrasound) with chest tube output of <150 mL in a 24-h period signifes readiness for chest tube removal when placed for pleural effusion.

Pleural Drainage Systems

Pleural drainage systems are connected to chest tubes to prevent air entry into the pleural space while allowing for the drainage of air or pleuraluid during the treatment of pneumothorax or pleural effusion, respectively. There are an increasing number of pleural drainage systems, but all serve this same basic function.