REBEL Core Cast 34.0 – Chest Tubes

Take Home Points

  • Small to Moderate Size Pneumothorax – consider managing conservatively with observation (need to make sure consulting services on same page)
  • Needle aspiration for spontaneous pneumothorax recommend by British Thoracic and European Respiratory Societies
  • 1 in 5 patients requiring a chest tube will suffer complications – many are iatrogenic in nature. Practice procedure via simulation 
  • Chest tubes placed for traumatic pneumothoraces should get prophylactic antibiotics
  • When deciding on treatment strategy, discuss with your consultants and make sure you have institutional buy-in.

REBEL Core Cast 34.0 – Chest Tubes

Spontaneous Pneumothorax Management

  • Traditional teaching was to put a small-bore chest tube and admit the patient
  • NEJM study offers evidence for conservative management and observation: Conservative versus Interventional Treatment for Spontaneous Pneumothorax
  • Randomized trial
  • Patients were randomized to either observation or invention with small bore (<12 french) chest tube
    • Repeat CXR done at 1 hour
    • Re-expansion of lung and no air leak, tube was clamped and repeat CXR at 4 hours
    • No Recurrent of PTX, chest tube pulled and patient discharged
    • Patient reassessed between 24-72 hours and had follow up visits with repeat car at 2, 4 and 8 weeks
  • Authors found that patients with primary spontaneous pneumothorax observation was not inferior to intervention
  • Observation group did take nearly twice as long to achieve radiographic resolution (16d v 30d) – non-patient centered outcome
  • Symptom resolution similar and observation group had less adverse events.
    • Less recurrence, less days hospitalized, less days of missed work, less procedures and less hospital revisits

Need Aspiration

  • Typically performed at 2nd Intercostal space in the midclavicular line. However please review the last core cast about why needle decompression in this area is not ideal. 
  • Instead, perform this procedure at the 4th or 5th intercostal space in anterior axillary line
    • Easier to identify, less critical structures and thinner area
  • Perform using US guidance – check landmarks to be sure going into the right area
    • Use 8cm 14 gauge angiocath and attach to 3 way stop cock, attach to either 50cc syringe or cavity drainage tray.
  • No robust literature on needle aspiration
    • 2017 Cochrane review found that tube thoracostomy outperformed need aspiration in immediate success rate
      • No difference in early failure rate, one-year success rate and hospitalization rate
      • Needle aspiration associated with less adverse events

Size Matters

  • Simple pneumo with just air in pleural space – no blood / pus / effusion than 14 french pigtail catheter is appropriate
  • American College of Chest Physicians (ACCP) recommends stable patients with pneumothorax get small bore and the unstable patient gets a small to moderate-sized chest tube.
  • ACCP tube classifications
    • Small-bore 7-14 french
    • Moderate 16-22 french
    • Large >24 french


  • More viscous fluid like blood or pus requires a larger tube for appropriate drainage. 
  • Rate of drainage is directly proportional to diameter of the tube
  • ATLS recommends 28-32 french chest tube for traumatic hemo-pneumo thorax

Chest Tube Complications

  • Early complications
    • Iatrogenic – insertional complication if tube placed into adjacent structure.
      • Lung most common structure damaged
    • Positional – tube within cavity but the position is not optimal 
      • Difficult to adjust – one sterile field is broken chest tube cannot be advanced 
  • Late Complications
    • Chest tube removal leading to reaccumulation of pneumothorax
    • Infection – cellulitis, empyema and pneumonia
    • Malfunction – persistent air leak because of bronchopulmonary fistula
    • Obstruction – occlusion with blood or pus


  • Primary spontaneous pneumothorax – no good evidence for routine use of antibiotic prophylaxis
  • Chest tube s/p chest trauma – recommendation for antibiotics.
    • Meta-analysis showed antibiotics reduced the risk of empyema and pneumonia

More on the Topic

Shownotes Written By: Miguel Reyes, MD (Twitter: @miguel_reyesMD)

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

Cite this article as: Anand Swaminathan, "REBEL Core Cast 34.0 – Chest Tubes", REBEL EM blog, May 27, 2020. Available at:

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