Give me notes on chest tube intubation , indicaiton, contraindications, surveillance,how to see drainage and tube , how to monitor such patient , when to extubate , .in ward patient .. different criterias or values to remember , give mnemonics wherever possible .. I am a first PGR MD medicine , also preparing for MRCP .
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chest tube insertion indications contraindications monitoring removal criteria MRCP ward management
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chest tube indications contraindications monitoring removal criteria drainage assessment
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Chest Tube (Intercostal Drain / Tube Thoracostomy) - Complete Ward Notes
For PGR MD Medicine & MRCP Preparation
1. ANATOMY REMINDER (Quick)
The tube is inserted in the "safe triangle" (Triangle of Safety):
- Anterior border: lateral edge of pectoralis major
- Posterior border: anterior border of latissimus dorsi
- Inferior border: 5th intercostal space (nipple level)
- Apex: axilla
Always insert over the UPPER BORDER of the rib below (to avoid the neurovascular bundle - Vein, Artery, Nerve run in the groove below each rib, from top to bottom).
Mnemonic: VAN (Vein, Artery, Nerve) - go above the rib below, never below the rib above.
2. INDICATIONS
Mnemonic: "PHA-CE-T"
| Letter | Indication |
|---|---|
| P | Pneumothorax (tension, large spontaneous, bilateral, mechanically ventilated) |
| H | Hemothorax |
| A | Air leak post-surgery / bronchopleural fistula |
| C | Chylothorax |
| E | Empyema / parapneumonic effusion meeting drainage criteria |
| T | Traumatic effusion / large symptomatic pleural effusion |
Additional specific indications:
- Post-thoracic surgery (prophylactic/therapeutic)
- Occult pneumothorax in patients on positive pressure ventilation
- Malignant effusion (for pleurodesis)
- Re-expansion after oesophageal/thoracic procedures
Empyema drainage criteria - drain if ANY of:
- Frank pus on aspiration
- Organisms on Gram stain or culture positive
- Pleural fluid pH < 7.2
- Pleural fluid glucose < 2.2 mmol/L (40 mg/dL)
- Loculated on imaging
3. CONTRAINDICATIONS
No ABSOLUTE contraindications (in a life-threatening emergency such as tension pneumothorax, always insert)
Relative contraindications - Mnemonic: "CLAMP"
| Letter | Contraindication |
|---|---|
| C | Coagulopathy (correct if non-emergent; INR >1.5 or platelets <50,000 are relative cautions) |
| L | Loculated effusion (complex anatomy - needs imaging guidance) |
| A | Adhesions / prior thoracic surgery (altered anatomy) |
| M | Major bullous disease / emphysema (risk of fistula) |
| P | Pus/cellulitis at proposed site (choose alternative site) |
4. TUBE SIZE SELECTION
| Indication | Tube Size |
|---|---|
| Pneumothorax (simple) | Small-bore 8-14 Fr (Seldinger/pigtail) |
| Pleural effusion / empyema | 12-16 Fr (small-bore adequate in most; guided by image) |
| Haemothorax / trauma | 28-36 Fr (large-bore; must allow blood clots) |
| Post-thoracic surgery | 28-32 Fr |
Key MRCP point: MIST trial showed no difference in outcomes between small-bore and large-bore for empyema, but large-bore caused significantly more pain. Small-bore (12 Fr) provided definitive treatment in 78% of pleural infection cases.
5. THE THREE-CHAMBER DRAINAGE SYSTEM (Pleurevac / Underwater Seal)
[PATIENT] --> [Collection Chamber] --> [Water Seal Chamber] --> [Suction Control Chamber] --> [Suction source]
Chamber functions:
| Chamber | Function | What to look for |
|---|---|---|
| 1. Collection chamber | Collects drained fluid | Volume, colour, character |
| 2. Water seal chamber | One-way valve; 2 cm H₂O water column | Tidaling, bubbling |
| 3. Suction control chamber | Sets negative pressure applied | Gentle continuous bubbling (active); no bubbling (water seal only) |
Standard suction: -20 cm H₂O
6. SURVEILLANCE / MONITORING THE DRAINAGE SYSTEM
6A. What to look for at the bedside
Mnemonic: "CABT" - Check every shift
| Sign | Meaning |
|---|---|
| C - Colour/Character of drainage | See table below |
| A - Air leak (bubbling in water seal) | See below |
| B - Bubbling in suction chamber | Normal if on suction; should be gentle |
| T - Tidaling in water seal | Normal oscillation with respiration |
6B. Interpreting Drainage Character
| Drainage appearance | Likely cause |
|---|---|
| Serous/straw-coloured | Simple effusion, resolving empyema |
| Haemoserous | Post-op, early haemothorax |
| Frank blood (bright red) | Active haemorrhage - act quickly |
| Cloudy/turbid | Empyema |
| Milky white | Chylothorax (disrupted thoracic duct) |
| Dark old blood | Old haemothorax |
Haemothorax: when to worry (operative criteria):
- Initial drainage > 1000-1500 mL immediately on insertion
- Ongoing loss > 200 mL/hour for 2-4 hours
- Total drainage > 1500 mL in first 24 h
These indicate need for surgical intervention (VATS or thoracotomy)
6C. Air Leak Assessment
Check water seal chamber:
| Finding | Interpretation |
|---|---|
| Bubbling only on cough/Valsalva | Small/intermittent air leak |
| Bubbling continuously | Significant ongoing air leak or bronchopleural fistula |
| No bubbling | No air leak (lung likely re-expanded) or tube blocked |
Air leak grading (clinical system):
- Grade 1: On forced cough only
- Grade 2: On normal cough
- Grade 3: On normal breathing (continuous)
To assess air leak: Drain all fluid from the tubing into the collection chamber, then ask patient to perform a vigorous cough. No bubbles = no air leak = safe to remove.
6D. Tidaling (Swing / Oscillation)
Tidaling = rise in water seal during inspiration, fall during expiration (opposite in ventilated patients)
| Tidaling | Meaning |
|---|---|
| Present | Tube patent, in pleural space |
| Absent | Either: lung fully expanded (pleural space obliterated) OR tube kinked/blocked/outside pleural space |
If tidaling suddenly stops: check for kinks, check CXR for tube position, check if lung fully expanded.
7. HOW TO MONITOR THE PATIENT ON THE WARD
Daily monitoring checklist - Mnemonic: "DRAPES"
| Letter | Check |
|---|---|
| D | Drainage volume (24-hour total, colour) |
| R | Respiratory rate, oxygen saturation, auscultation |
| A | Air leak assessment (bubbling in water seal) |
| P | Pain score - analgesia review |
| E | Entry site inspection (dressing, tube position, subcutaneous emphysema) |
| S | Swing/tidaling, system integrity (all connections taped, bottle below chest level) |
System integrity rules:
- Drainage bottle always at least 60-100 cm BELOW the patient's chest (gravity dependent)
- All joints firmly taped
- Tube not kinked
- Do NOT clamp routinely (risk of tension pneumothorax)
When IS clamping acceptable?
- To locate an air leak (briefly)
- During tube change
- Brief clamping before removal in some protocols (controversial)
- NEVER clamp if there is an active air leak - risk of tension pneumothorax
Investigations on ward:
- CXR within 24 hours of insertion (confirm position, assess re-expansion)
- Daily CXR not mandatory in stable, asymptomatic patients - use clinical assessment
- CT chest if tube not draining as expected, loculated collection, or uncertain tube position
- U&E, FBC, coagulation - baseline and if ongoing bleeding
Re-expansion pulmonary oedema:
- Risk when rapidly draining large effusions
- Limit initial drainage to 1000-1500 mL then clamp for 1-2 hours before continuing
- Presents as: cough, frothy sputum, hypoxia, CXR infiltrate after drainage
8. WHEN TO REMOVE THE CHEST TUBE (Extubation Criteria)
Mnemonic: "FLAME" - remove the tube when FLAME is out
| Letter | Criterion |
|---|---|
| F | Flow stopped - drainage < 150-200 mL/24 hours (some use < 400 mL/24 h for non-surgical patients) |
| L | Lung re-expanded on CXR (no pneumothorax, no residual fluid) |
| A | Air leak absent (no bubbling on cough) - for 24 hours |
| M | Medical condition resolved (e.g., infection controlled, no active bleeding) |
| E | Expansion confirmed - patient can tolerate off-suction (water seal trial) |
Specific values:
- Drainage < 150 mL/24h (Pfenninger & Fowler textbook)
- OR < 200-300 mL/24h (Level 1 recommendation, most guidelines)
- Some evidence supports removal at 400-450 mL/day - is also safe (selective cases)
- No air drainage for 24 hours
- No air leak on forceful cough or Valsalva
Pre-removal protocol:
- Switch from suction to water seal for 4-6 hours
- Check CXR after this trial (to detect slowly recurrent pneumothorax)
- If stable - proceed to removal
- Clamping trial is NOT always necessary or preferred - especially if other criteria met
9. REMOVAL PROCEDURE (Step-by-Step)
- Analgesia first - IV analgesia 30 mins before; can infiltrate 5 mL 1% lidocaine around tube exit site
- Prepare: petroleum jelly gauze, sterile 4x4 gauze, Elastoplast/Tensoplast
- Cut securing sutures
- Timing of removal - on expiration to prevent air entry:
- Conscious patient: "Take a deep breath in, breathe out, hold it" - pull during breath-hold at end-expiration
- Alternatively: ask patient to hum (Valsalva equivalent)
- Ventilated patient: remove at end-inspiration (positive pressure moment)
- Swiftly and smoothly pull the tube in one motion
- Immediately apply petroleum gauze (occlusive dressing) - seal the tract
- Apply pressure dressing and tape firmly
- CXR in 6-12 hours post-removal (check for pneumothorax)
- Review wound at 48 hours; dressing can be removed then
Mnemonic for removal timing: "OUT on breathing OUT" (or hum it out)
10. COMPLICATIONS
Mnemonic: "IRISH SET"
| Complication | Notes |
|---|---|
| I - Injury to vessels/organs | Heart, great vessels, lung, liver, spleen, diaphragm |
| R - Re-expansion pulmonary oedema | Limit drainage to 1000-1500 mL initially |
| I - Infection / empyema | Prophylactic 1st-gen cephalosporin reduces risk |
| S - Subcutaneous emphysema | Side hole outside pleural space; increase suction, may need 2nd tube |
| H - Haemorrhage | Intercostal artery injury |
| S - Subdiaphragmatic placement | CXR / CT to verify |
| E - Empyema (iatrogenic) | Sterile technique mandatory |
| T - Tension pneumothorax | NEVER clamp with active air leak |
11. KEY VALUES TO REMEMBER (MRCP / Exam Focus)
| Parameter | Value |
|---|---|
| Safe triangle 5th ICS level | Nipple level / inframammary fold |
| Standard suction | -20 cm H₂O |
| Bottle position below chest | ≥ 60-100 cm |
| Remove when drainage < | 150-200 mL/24h |
| Limit initial pleural drainage to | 1000-1500 mL (avoid re-expansion oedema) |
| Haemothorax - operative threshold (initial) | >1000-1500 mL immediately |
| Haemothorax - ongoing loss threshold | >200 mL/hour for 2-4 hours |
| Empyema drainage: pH threshold | pH < 7.2 |
| Empyema drainage: glucose threshold | < 2.2 mmol/L (40 mg/dL) |
| Light's criteria exudate: protein ratio | Pleural:serum protein > 0.5 |
| Light's criteria exudate: LDH ratio | Pleural:serum LDH > 0.6 |
| Light's criteria exudate: absolute LDH | > 2/3 upper limit of normal serum LDH |
| Post-removal CXR timing | 6-12 hours after removal |
| Water seal trial before removal | 4-6 hours |
| Subcutaneous air resolution time | 7-10 days |
| Prophylactic antibiotic (trauma/surgery) | 1st-gen cephalosporin (duration controversial) |
12. QUICK MNEMONICS SUMMARY CARD
| Mnemonic | What it covers |
|---|---|
| VAN | Neurovascular bundle order (Vein-Artery-Nerve) - insert over upper rib border |
| PHA-CE-T | Indications (Pneumothorax, Haemothorax, Air leak, Chylothorax, Empyema, Trauma/effusion) |
| CLAMP | Contraindications (Coagulopathy, Loculation, Adhesions, Major bullae, Pus at site) |
| CABT | Daily drain checks (Colour, Air leak, Bubbling, Tidaling) |
| DRAPES | Patient monitoring (Drainage, Resp status, Air leak, Pain, Entry site, Swing) |
| FLAME | Removal criteria (Flow stopped, Lung expanded, Air leak absent, Medical cause resolved, Expansion confirmed) |
| IRISH SET | Complications |
| OUT on breathing OUT | Timing of tube removal |
13. SPECIAL WARD SCENARIOS
1. Tube not draining but lung not fully expanded on CXR:
- Check for kinks, dependent loops, clots
- Irrigate with 20-30 mL sterile saline via 3-way stopcock
- Check all side holes are within pleural space on CXR
- CT chest if unclear
2. Subcutaneous emphysema developing with tube in situ:
- Side hole likely outside pleural space OR massive leak overwhelming tube
- CXR urgently - check all fenestrations within chest
- Increase suction gradually
- If progressive despite max suction - insert 2nd tube (CT guidance preferred)
- Reassure patient - rarely dangerous; takes 7-10 days to resolve spontaneously
3. Sudden large increase in drainage (bright red blood):
- Active haemorrhage - alert surgeon immediately
- Check haemodynamic status
-
200 mL/hour x 2-4 hours = operative intervention likely needed
4. Persistent air leak >5-7 days:
- Consider bronchopleural fistula
- Bronchoscopy, VATS, or oesophagoscopy to find source
- Surgical referral
5. Patient on positive pressure ventilation with pneumothorax:
- Even a small pneumothorax can tension under PPV
- Low threshold for chest tube insertion
- Monitor very closely; do not observe conservatively on NIV/IPPV
14. MRCP FAVOURITE POINTS
- Light's criteria - know all three arms (protein ratio >0.5, LDH ratio >0.6, absolute LDH > 2/3 ULN)
- Serum-pleural albumin gradient > 1.2 g/dL confirms transudate misclassified by Light's criteria (e.g., heart failure on diuretics)
- MIST trial: no outcome difference between small and large bore tubes for pleural infection; large bore causes more pain
- pH < 7.2 in parapneumonic effusion = drain it
- Re-expansion pulmonary oedema: cap initial drainage at 1,500 mL
- Removal threshold: < 200 mL/24h + no air leak + lung expanded
- Remove tube at end-expiration in spontaneously breathing patients
- No routine clamping - tension pneumothorax risk
- BTS (British Thoracic Society) guidelines: small-bore first for non-traumatic haemothorax, empyema, effusion
Sources: Murray & Nadel's Textbook of Respiratory Medicine; Pfenninger and Fowler's Procedures for Primary Care; Rockwood & Green's Fractures in Adults 10th ed; Fishman's Pulmonary Diseases; PMC10275667 (Chest Tube Placement and Management: A Practical Review); UAB/VUMC institutional protocols
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