What size chest tube? What drainage system is ideal? And other chest tube management questions

Chest tubes and their accompanying pleural drainage units continue to present challenging questions regarding their optimal use. Appropriate chest tube size selection to accommodate the clinical situation is key, especially in the setting of large pleural air leaks lest a tension pneumothorax ensue. Connection of an appropriate pleural drainage unit to the chest tube is equally important to obviate impeding airflow after successful evacuation by the chest tube. Large-bore chest tubes are generally required for patients with pneumothoraces, regardless of etiology, if the patient is mechanically ventilated, or for patients requiring drainage of viscous pleural liquids such as blood. Smaller bore tubes may be adequate in patients with limited production of pleural air or of free-flowing pleural liquid. Chest tubes may be removed successfully at either end expiration or end inspiration, and potentially as soon as less than or equal to200 mL/fluid output per day is achieved. Additional prospective studies are needed to provide evidence-based answers to the many questions remaining regarding chest tube placement, ongoing management, and removal.