When to remove a chest tube based on output?

What is the ideal chest tube output volume threshold prior to removal in trauma patients?

 According to Younes et al. "When to Remove a Chest Tube? A randomized study with subequent prospective consecutive validation"  -

They performed a Randomized controlled trial of 139 patients with chest tubes s/p thoracotomy and lung resection.

Tubes were removed at 100 ml/d, 150 ml/d, 200 ml/d.

There was no difference in outcome - drainage time, length of stay, reaccumulation rate (9% vs. 13% vs 5%) or need for thoracentesis.

Note: Chest tubes were placed to waterseal for 24h.  Post-pull CXR were obtained, and needle thoracostomies were performed for post pull PTX over 10%.

Another randomized controlled trial was performed by Hessami et al. "Volume Threshold for Chest Tube Removal: A Randomized Controlled Trail" -

138 patients had chest tubes for trauma or malignancy.  Tubes were removed at 150 ml/d vs. 200 ml/d.  There was a significantly decreased length of stay in the group removed under 200ml (4.8 vs. 4.1 days, p=0.04).  There was no difference in reaccumulation rate (7.1 vs. 8.8%) or need for thoracentesis(4.3%).

Note: Chest tubes were removed at maximal inspiratory effort with occlusive dressing.  Follow/up CXR were obtained at 8-10h to evaluate for reaccumulation and blunting of costophrenic angle on upright CXR prompted thoracentesis.

In regards to a primary trauma population, Martin et al.  studied an algorithm in 313 trauma patients with chest tubes in "Results of a clinical practice algorithm for the management of thoracostomy tubes placed for traumatic mechanism".

87% were blunt trauma, 13% were penetrating.  Chest tubes were removed below 200 ml/d, after being placed on water seal for 24 hours

Retrospective review of 313 pts w/ CT placement for trauma → mgmt algorithm.  CT removal <200cc/d.  4.1% complication rate.

There was an overall 4.1% complication rate including:  2 patients required thoracotomy, and 11 required another chest tube.  The mean length of chest tube placement was 5.9 days.

IN SUMMARY:

No clear volume threshold for CT removal.

Level I evidence for CT removal <200cc/d, though mixed population.

Threshold of 450cc/d also has been demonstrated for malignancy resection.

Trauma-related CT mgmt algorithm incorporated 200cc threshold.

by: Laura Humphries, MD

Ben Ferguson, MD

Nadine Peart, MS4