Journal of

Clinical Medicine

Review
Chest Tubes and Pleural Drainage: History and Current Status
in Pleural Disease Management
Claudio Sorino 1, * , David Feller-Kopman 2 , Federico Mei 3,4 , Michele Mondoni 5 , Sergio Agati 1 ,
Giampietro Marchetti 6 and Najib M. Rahman 7,8

1 Division of Pulmonology, Sant’Anna Hospital of Como, University of Insubria, 21100 Varese, Italy;
sergio.agati@asst-lariana.it
2 Section of Pulmonary and Critical Care Medicine, Dartmouth-Hitchcock Medical Center,
Lebanon, NH 03766, USA; david.j.feller-kopman@hitchcock.org
3 Respiratory Diseases Unit, Department of Internal Medicine, Azienda Ospedaliero Universitaria delle Marche,
60126 Ancona, Italy; f.mei@staff.univpm.it
4 Department of Biomedical Sciences and Public Health, Polytechnic University of Marche, 60126 Ancona, Italy
5 Respiratory Unit, ASST Santi Paolo e Carlo, Department of Health Sciences, Università degli Studi di Milano,
20122 Milan, Italy; michele.mondoni@unimi.it
6 Pulmonology Unit, ASST Spedali Civili, 25123 Brescia, Italy; marchetti.giampietro@libero.it
7 Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust,
Oxford OX3 9DU, UK; najib.rahman@ndm.ox.ac.uk
8 Oxford Respiratory Trials Unit, University of Oxford, Oxford OX3 7LE, UK
* Correspondence: claudio.sorino@uninsubria.it

Abstract: Thoracostomy and chest tube placement are key procedures in treating pleural diseases
involving the accumulation of fluids (e.g., malignant effusions, serous fluid, pus, or blood) or air
(pneumothorax) in the pleural cavity. Initially described by Hippocrates and refined through the
centuries, chest drainage achieved a historical milestone in the 19th century with the creation of
closed drainage systems to prevent the entry of air into the pleural space and reduce infection
risk. The introduction of plastic materials and the Heimlich valve further revolutionized chest
tube design and function. Technological advancements led to the availability of various chest tube
Citation: Sorino, C.; Feller-Kopman, designs (straight, angled, and pig-tail) and drainage systems, including PVC and silicone tubes
D.; Mei, F.; Mondoni, M.; Agati, S.; with radiopaque stripes for better radiological visualization. Modern chest drainage units can
Marchetti, G.; Rahman, N.M. Chest incorporate smart digital systems that monitor and graphically report pleural pressure and evacuated
Tubes and Pleural Drainage: History fluid/air, improving patient outcomes. Suction application via wall systems or portable digital devices
and Current Status in Pleural Disease
enhances drainage efficacy, although careful regulation is needed to avoid complications such as
Management. J. Clin. Med. 2024, 13,
re-expansion pulmonary edema or prolonged air leak. To prevent recurrent effusion, particularly due
6331. https://doi.org/10.3390/
to malignancy, pleurodesis agents can be applied through the chest tube. In cases of non-expandable
jcm13216331
lung, maintaining a long-term chest drain may be the most appropriate approach and procedures
Academic Editors: Teruhiko Imamura such as the placement of an indwelling pleural catheter can significantly improve quality of life.
and Epaminondas G. Zakynthinos
Continued innovations and rigorous training ensure that chest tube insertion remains a cornerstone
Received: 21 September 2024 of effective pleural disease management. This review provides a comprehensive overview of the
Revised: 8 October 2024 historical evolution and modern advancements in pleural drainage. By addressing both current
Accepted: 21 October 2024 technologies and procedural outcomes, it serves as a valuable resource for healthcare professionals
Published: 23 October 2024 aiming to optimize pleural disease management and patient care.

Keywords: chest tube; pleural effusion; empyema; pneumothorax; drainage

Copyright: © 2024 by the authors.

Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
1. Introduction
conditions of the Creative Commons Pleural drainage consists of inserting a flexible tube, called a chest tube or thoracos-
Attribution (CC BY) license (https:// tomy tube, through the chest wall into the pleural space. It is an essential procedure in
creativecommons.org/licenses/by/ both the diagnostic and therapeutic management of pleural diseases including pleural effu-
4.0/). sion, empyema, hemothorax, and pneumothorax. Instruments and techniques for pleural

J. Clin. Med. 2024, 13, 6331. https://doi.org/10.3390/jcm13216331 https://www.mdpi.com/journal/jcm

J. Clin. Med. 2024, 13, 6331 2 of 18

drainage have evolved significantly over time, reflecting advances in medical technology
and a deeper understanding of pleural pathophysiology [1].

2. Historical Background
The concept of pleural drainage dates back to ancient times. Hippocrates (460–370 BC)
is often credited with describing the first form of pleural drainage using hollow reeds to
drain empyemas [2]. However, it was only in the 19th century that chest tube thoracostomy
as we recognize it today began to take its current form [3].

2.1. Nineteenth Century Developments

Before the development of antibiotics, closed-space infections were almost exclusively
the concern of surgeons, who generally approached them with early, aggressive, and open
drainage. Little was known about the pathophysiology of the pleural space and open
pneumothorax was considered the inevitable consequence of surgical evacuation except
for cases in which the empyema caused adhesions between the visceral and parietal pleura,
thus preventing lung collapse.
In 1871, British physician William Smoult Playfair devised subaqueous drainage to
fully drain thoracic empyemas in children while preventing air from entering the pleural
cavity [4]. Similarly, in 1875, German internist Gotthard Bülau introduced the closed
drainage system using a siphon principle, which significantly reduced the risk of infection
compared to open drainage [5]. Although Bülau’s technique was published in 1891, it was
rarely used for several years.

2.2. Twentieth Century Advancements

In 1917–1918, during World War I, the influenza pandemic led to many cases of
subsequent group-A streptococcal pneumonia and hemorrhagic pleural effusions in military
camps, with very high mortality rates despite the use of open drainage. It was during this
time that Evarts Ambrose Graham, a captain in the Army Medical Corps, was appointed
to the U.S. Army Empyema Commission and began treating empyema successfully with
closed drainage systems [6].
The World War II period saw further advancements in the emergency use of chest tubes
for pleural diseases in soldiers. Indeed, the need for effective management of traumatic
hemothorax and pneumothorax spurred innovations in chest drainage systems.
The introduction of plastic materials in the mid-20th century revolutionized chest
tube design, making them more flexible and less prone to kinking. Closed thoracostomy
and underwater seal drainage became the standard of care for blunt thoracic trauma and
treatment in the Vietnam War [7].
In 1968, Heimlich designed a unidirectional valve which, when connected to the
drainage tube, ensured the drainage of gas or fluid from the pleural space without back-
flow [8]. This system was sterile and disposable and had the advantage of allowing patient
ambulation compared to bulky underwater drainage bottles.

3. Modern Equipment
Modern chest tube thoracostomy involves several key components (a tube, a drainage
system, and a suction system) and techniques designed to improve patient outcomes,
reduce clogging, and minimize complications.

3.1. Chest Tubes

Chest tubes are typically made from polyvinyl chloride (PVC) or silicone, and vary in
size and design to suit different clinical scenarios. With the advancement of technology,
various types of chest tubes have been developed. They can be straight, angled, spiral,
or coiled at the end (referred to as “pig-tail”). They can drain through a central channel,
with distal fenestrations at the tip and sides, or have several channels (i.e., a Blake drain,
Ethicon, USA) to facilitate pleural fluid drainage. A radiopaque stripe aids tube recognition
J. Clin. Med. 2024, 13, 6331 3 of 18

in chest X-rays and there is typically a marker that is a set distance to the most proximal
drain hole (sentinel hole). Some tubes can have a double lumen for aspiration or infusion
simultaneously [9]. It should be noted that the shape of the tube and their ability to “lock”
are completely separate—and indeed, locking chest tubes should be avoided in pleural
drainage due to the risk of intercostal artery laceration on removal.
The size of a chest tube is typically measured according to the French system, where it is
expressed in “Ch” (Charrière, from the name of the creator) or more simply in “Fr” (French,
from the country where Charrière lived) [10]. The value of Ch or Fr corresponds to the
external circumference of the catheter, so the diameter in millimeters can be approximately
calculated by dividing the “Fr” by 3. For example, a 12 Fr/Ch tube has an external diameter
of about 4 mm.
Commonly “small-bore” chest tubes (SBCTs) range from 8 to 14 Fr and their insertion
is less invasive. They are the tubes most commonly used to drain air (pneumothorax) as
well as all different types of pleural effusion (including empyema and hemothorax), due
to their high maneuverability, limited complications, and better tolerability by patients in
comparison with large-bore chest tubes (LBCTs) [11].
Among LBCTs (>14 Fr), those with a diameter between 16 and 24 Fr (sometimes
referred to as medium-bore chest tubes) are often used for draining air or liquids including
pus and blood, whereas 28 to 36 Fr tubes are usually reserved for draining thick fluids
(hemothorax, empyema), especially in cases of severe trauma, need for rapid evacuation,
or post-surgical drainage where there may be a large air leak. Larger tubes unavoidably
lead to greater pain and complications. Figure 1 shows some commonly used types of
chest tubes.
Note that large-bore tubes should not be inserted with a trocar due to the risk of
tissue damage and complications. Blunt dissection is preferred, as it minimizes trauma and
allows for safer placement compared to the guide wire technique, which is better suited to
smaller catheters.

3.2. Chest Drainage Units

An adequate chest drainage system aims to remove pleural fluid and/or air, pre-
vent their reflux into the pleural space, and restore negative pleural pressure (less than
atmospheric pressure) to allow lung re-expansion [12].
Overall, a chest drainage unit (CDU) is a sterile, disposable device consisting of a
flexible tube connected to one or more chambers that collect the fluid, to be positioned
below the level of the chest tube insertion to allow the fluid to escape by means of gravity.
CDUs have evolved significantly since their introduction but essentially include one-
way valves (Heimlich valve) or water-seal drainage systems to prevent the backflow of air
or fluid into the pleural space.
An underwater-seal chest drainage system consists of a two- or three-chamber plastic
unit with vertical columns displaying milliliter measurements (Figure 2). Their develop-
ment stems from the original single-bottle system designed by Bülau, where a rigid straw,
connected to the chest tube, entered the bottle and found itself with the tip immersed in
saline solution. An opening with a one-way valve allowed air to escape and prevented
pressure build-up in the system. However, the one-bottle system works well if only air exits
the pleural cavity, whereas if a pleural effusion is drained, the fluid level in the bottle will
increase and reduce the efficiency of removing additional air or fluid from the patient [12].
In two-bottle systems, the first bottle is responsible for collecting fluid, whereas the
second bottle contains the water seal. They are preferred over the one-bottle system when
large quantities of pleural liquid are drained, as fluid drainage does not affect the pressure
gradient for further evacuation of fluid or air from the pleural space. Three-bottle systems
have a third bottle or chamber, which is useful if suction is required.
 J. Clin. Med. 2024, 13, x FOR PEER REVIEW 4 of 19
J. Clin. Med. 2024, 13, 6331 4 of 18

Figure 1. Main types of pleural drainage with details of the tips. (A): small-bore straight catheter with
Figure 1. Main types of pleural drainage with details of the tips. (A): small-bore straight catheter
awith
Verres-type needleneedle
a Verres-type dilator; (B): small-bore
dilator; pig-tail
(B): small-bore catheter;
pig-tail (C): small-bore
catheter; straight
(C): small-bore catheter
straight with
catheter
guide wire for placement by means of the Seldinger technique; (D): large-bore catheter with
with guide wire for placement by means of the Seldinger technique; (D): large-bore catheter with trocar.
trocar.
J.J.Clin.
Clin.Med.
Med.2024,
2024,13,
13,x6331
FOR PEER REVIEW 6 of 19
5 of 18

Figure
Figure 2.
2. Exemplification of the
Exemplification of theclassic
classicunderwater-seal
underwater-sealchest
chestdrainage
drainage systems
systems with
with oneone
(A),(A),
twotwo
(B),
(B),
andand three
three (C) (C) chambers,
chambers, andand a modern
a modern collection
collection box box
(D).(D).

3.3. Suction Systems

All these for Pleural
chambers Drainage integrated into modern, multifunctional, easy-to-
are currently
manage boxes. Recently, smart
The application of suction to digital drainage
pleural systems
drainage systemshave been
can introduced,
be useful capable
in particular
of recording the flows of evacuated air or liquid, monitoring the pleural
conditions not resolved by gravity drainage alone, to facilitate lung re-expansion and fluid pressure, and
graphically reporting all the data [13,14].
or air removal. Data regarding the efficacy of suction following open or thoracoscopic lung
surgery are controversial [15–18]. Similarly, data to support the hypothesis of a benefit in
3.3. Suction Systems for Pleural Drainage
patients with pneumothorax are weak [19]. In theory, lung expansion obtained through
externalThesuction
application
wouldofallowsuctiontheto pleural drainage
apposition systems
of the visceral and can be useful
parietal in particular
pleura to exert a
conditions not resolved by gravity drainage alone, to facilitate lung
compression effect on the area of a visceral pleural defect and consequently stop air re-expansion andleaks.
fluid
or air removal. Data regarding the efficacy of suction following
However, excessive negative intrapleural pressure produced by suction may induce an open or thoracoscopic
lung surgery
increased are through
airflow controversial [15–18].
the defect, Similarly,
especially in data to support
patients the hypothesislung
with non-expandable of a
benefit in patients with pneumothorax are weak [19]. In theory, lung expansion
[20,21]. Traditional water-seal CDUs have been associated with a significantly shorter du- obtained
through
ration external suction
of postoperative airwould
leak andallow
chestthedrainage
apposition of the visceral
compared and parietal
with continuous pleura
suction andto
exert adrainages
digital compression [22].effect
The on the area of
application ofasuction
visceralshould
pleuralbedefect and immediately
avoided consequentlyafter
stop
air leaks. However, excessive negative intrapleural pressure produced
chest tube insertion as it may increase the risk of re-expansion pulmonary edema, partic- by suction may
induce an increased airflow through the defect, especially in patients with non-expandable
ularly in young patients with complete pneumothorax or if the lung has been deflated for
lung [20,21]. Traditional water-seal CDUs have been associated with a significantly shorter
a prolonged time [23,24].
duration of postoperative air leak and chest drainage compared with continuous suction
Water seals regulate the amount of suction through the height of a column of water
and digital drainages [22]. The application of suction should be avoided immediately
in the suction control chamber. The suction control chamber is filled with water to the
after chest tube insertion as it may increase the risk of re-expansion pulmonary edema,
desired level. An external vacuum source generates negative pressure pulling air through
particularly in young patients with complete pneumothorax or if the lung has been deflated
the water column. The water column height resists this pull, thereby regulating the suction
for a prolonged time [23,24].
pressure to the set level. Wall suction provides consistent and adjustable suction pressure
Water seals regulate the amount of suction through the height of a column of water in
that is set by the depth of the column of liquid in the collection system and not by the
the suction control chamber. The suction control chamber is filled with water to the desired
suction read on the wall pressure gauge. With a 20 cmH2O water column in the suction
level. An external vacuum source generates negative pressure pulling air through the water
control chamber, the maximum suction pressure exerted on the pleural space will be −20
column. The water column height resists this pull, thereby regulating the suction pressure
cmH2O, regardless of the external vacuum source’s strength. This method ensures a
J. Clin. Med. 2024, 13, 6331 6 of 18

to the set level. Wall suction provides consistent and adjustable suction pressure that is set
by the depth of the column of liquid in the collection system and not by the suction read on
the wall pressure gauge. With a 20 cmH2 O water column in the suction control chamber,
the maximum suction pressure exerted on the pleural space will be −20 cmH2 O, regardless
of the external vacuum source’s strength. This method ensures a consistent and precise
level of suction. It requires regular checking and maintenance to ensure the water level is
correct, as evaporation could alter the water level over time [25]. Newer systems use a ‘dry’
technique, where the amount of suction is applied by a setting on the drainage box. As
with ‘wet’ systems, pressure to the patient can never be more negative than the pressure
set on the chest drain.
Wall suction can be used in inpatients as it utilizes the hospital’s central vacuum
system. The suction pressure is regulated through a control valve and applied to the
pleural drainage system via tubing connected to the drainage chamber. In addition to being
limited to hospital settings with central vacuum infrastructure, this system restricts patients’
mobility and involves a risk of applying excessive pressure if not properly regulated.
Portable suction devices can be used in both hospital and outpatient settings, particu-
larly for ambulatory patients or those requiring home care. They use battery or electrical
power to generate negative pressure, and are connected to the drainage system via tub-
ing, providing adjustable suction settings. These devices enhance patient mobility and
independence, although they can be less powerful than wall suction and require regular
maintenance and battery charging.
Mechanical suction regulators are used in conjunction with water-seal or dry suction
pleural drainage systems in hospitals to control the amount of negative pressure applied to
the drainage system. They are connected between the wall suction source and the drainage
system, ensuring that the pressure remains within a safe and therapeutic range, typically
between −10 and −20 cmH2 O. They require careful calibration and monitoring to ensure
effective function.

4. Clinical Applications
Chest tubes are employed in various pleural diseases, each with specific indications
and management protocols. Table 1 provides a summary of the indications for chest tube
placement in both pleural effusion and pneumothorax, including relevant descriptions.
Table 2 summarizes the decision-making factors and properties of chest tube types,
techniques of placement, and drainage systems, along with their advantages and drawbacks
based on the patient’s clinical context. Each method and system present advantages
and limitations, which should be weighed according to the patient’s condition, available
resources, and operator expertise.

Table 1. Main indications for chest tube insertion.

Condition Indication Description

Significant accumulation of fluid causing respiratory distress
Large Pleural Effusion
or hypoxemia
Complicated Parapneumonic Presence of infected fluid or pus in the pleural space (empyema)
Effusion/Empyema requiring drainage
Symptomatic effusion associated with malignancy, especially if
recurrent. A chest tube may allow chemical pleurodesis if
Malignant Pleural Effusion
significant contact between the visceral and parietal pleura
Pleural is achieved.
Effusion Accumulation of blood in the pleural space, often due to trauma or
Hemothorax
post-surgical complication
Accumulation of lymphatic fluid in the pleural space, often due to
Chylothorax
thoracic duct injury
Diagnostic purpose when the cause of effusion is unknown and
Pleural Effusion with unclear etiology
requires analysis of pleural fluid
Prevention or management of fluid accumulation after thoracic
Post-Surgical or Post-Procedure
surgery or procedures
J. Clin. Med. 2024, 13, 6331 7 of 18

Table 1. Cont.

Condition Indication Description

Significant accumulation of air causing respiratory distress
Large Pneumothorax
or hypoxemia
Presence of symptoms such as severe breathlessness, chest pain,
Symptomatic Pneumothorax
or hypoxemia
Medical emergency with hemodynamic instability requiring
Tension Pneumothorax immediate decompression (simple needle aspiration is usually the
first procedure in life-threatening situations)
Pneumothorax
Repeated episodes of pneumothorax after initial conservative
Recurrent Pneumothorax
management (thoracoscopy is another option)
Pneumothorax in the presence of underlying lung disease with a
Secondary Pneumothorax
higher risk of complications
Pneumothorax due to chest injury with significant air leaks or
Traumatic Pneumothorax
associated hemothorax

Table 2. Pros and cons of different types of chest tubes, insertion techniques, and chest drainage units
(CDU) based on the patient’s clinical picture.

Category Type Pros Cons Best Suited For

- Minimally invasive - Pneumothorax
Small Bore (≤14 Fr) - Limited drainage capacity
- Less painful - Malignant effusions
- Potential clogging
- Lower infection risk with low fluid volume

- More painful - Hemothorax

- Effective for large volumes of fluid/air
Large Bore (>14 Fr) - Higher risk of infection - Empyema
- Efficient drainage in
- Requires procedural - Traumatic
Chest Tubes hemothorax/empyema
expertise or surgeon pneumothorax

- Can kink or clog

- Minimally invasive - Malignant pleural
- Limited use in
Pig-tail Catheter - Less painful effusions
viscous fluids
- Coiled design reduces tissue trauma - Spontaneous
- Less effective in large
- Good for long-term use pneumothorax
pneumothoraces

- Limited control
- Rapid deployment over placement
Verres-type Needle - Tension pneumothorax
- Useful in emergencies - Higher risk of
(emergency)
- Minimally invasive misplacement or injury to
Insertion
lung parenchyma
Techniques
- Greater precision with wire guidance - More time-consuming - Pneumothorax
Seldinger Technique - Lower complication rates - Requires skilled operator - Non-emergency
- Can be used for small bore tubes - More equipment needed situations

- Limited suction control - Short-term use

Bag - Portable
- Inadequate for - Transport of
- Simple and cost-effective
continuous monitoring stable patients

- Limited monitoring
One-Chamber - Simple design capability - Small pneumothorax
- Low-cost - No automatic - Minor effusions
fluid separation
Chest - Limited to specific
Drainage - Allows air-fluid separation clinical conditions - Small to moderate
Two-Chamber
Unit - Moderate monitoring capabilities - Intermediate effusions
(CDU) suction control

- Bulky - Large effusions

- Provides air-fluid separation
Three-Chamber - Less portable - Continuous drainage
- Allows continuous suction with
- Requires proper setup and (e.g., hemothorax,
improved monitoring
training for use empyema)

- Real-time monitoring - Expensive - Post-operative care

Digital - Automated pressure regulation - Requires electricity - Complex pleural
- Improved patient outcomes - Not available in all settings effusions or air leaks

4.1. Pleural Effusion

Transudative effusions are typically managed medically, with chest tube drainage
reserved for symptomatic relief or diagnostic purposes [26]. These effusions are usually the
result of systemic conditions such as heart failure, liver cirrhosis, or nephrotic syndrome,
where the underlying issue causes fluid to accumulate in the pleural space [27]. Treatment
focuses on addressing the root cause, and in cases where significant symptoms, such as
J. Clin. Med. 2024, 13, 6331 8 of 18

breathlessness, occur, a chest tube may be inserted to drain the fluid and provide relief [28].
Refractory symptomatic transudative pleural effusions despite maximal therapy constitute
an indication for pleural drainage as an alternative to repeated thoracentesis [29].
Some observational evidence has supported the use of indwelling pleural catheters
(IPCs) in such patients, whose main role lies in the symptomatic management of malignant
pleural effusion. However, the data regarding transudates are not univocal and a recent
randomized trial did not highlight a significant difference in breathlessness palliation over
12 weeks between IPC and standard care with therapeutic thoracentesis. Thoracentesis was
associated with fewer complications, while IPCs reduced the number of invasive pleural
procedures [30].
In patients with refractory hepatic hydrothorax waiting for liver transplantation or for
whom it is contraindicated, transjugular intrahepatic portosystemic shunt (TIPS) placement
represents the most useful treatment, although serial thoracenteses and insertion of an IPC
represent possible second-line options [31,32].
Exudative effusions, on the other hand, are often associated with infections, malig-
nancy, or inflammatory diseases, resulting from local factors affecting the pleura, such as
increased capillary permeability, infection, or neoplastic pleura infiltration. Therapeutic
drainage via chest tube is commonly required not only to relieve symptoms but also to
obtain a sample for diagnostic analysis, which can guide further treatment [33].
In some instances, particularly when pleural effusion is recurrent, pleurodesis might
be an option to reduce the risk of relapses [34]. Pleurodesis can be performed via the
introduction of a sclerosing agent through the chest tube into the pleural space (“slurry
technique”), causing adherences between the pleural layers, obliterating the space, and
thus preventing the reaccumulation of fluid. This procedure is particularly beneficial in
malignant pleural effusions or chronic conditions where repeated fluid buildup significantly
impairs the patient’s quality of life. Pleurodesis can be achieved using various agents
such as talc, autologous blood, tetracycline, doxycycline, or bleomycin, and can also
be performed under direct visualization during medical thoracoscopy or video-assisted
thoracic surgery (VATS) to ensure even distribution of the sclerosant and maximize efficacy
(“poudrage technique”). Two large randomized trials have not shown a difference between
slurry and poudrage [35,36].
The TIME1 randomized clinical trial demonstrated that larger chest tubes (i.e., 24F) are
more efficient than smaller ones (12F) for inducing talc slurry pleurodesis in patients with
malignant pleural effusion [37]. The authors would certainly recommend a tube size greater
than 12F for pleurodesis attempts with talc due to issues with blockage in smaller tubes.

4.2. Complicated Parapneumonic Effusion or Empyema

A pleural effusion is defined as “complicated” when it becomes loculated, pH and
glucose fall, and LDH increases. Pleural thickening and an effusion occupying more than
half of the hemithorax may suggest a complicated parapneumonic effusion (CPE), though
neither of these features is specific to CPE. In this stage, antibiotic therapy alone is generally
not sufficient for healing. Empyema is a type of CPE characterized by the presence of
frank pus in the pleural cavity or a positive Gram stain or culture. CPE and empyema
require prompt drainage to increase the chances of resolving local infection, reduce the
risk of further spread of microbes and sepsis, and prevent long-term sequelae such as
fibrothorax [38]. The use of chest tubes in these settings is a well-established cornerstone of
therapeutic intervention.
CPE can progress through three stages: exudative, fibrinopurulent, and organizing.
In the early exudative phase, pleural fluid is free-flowing and can be easily drained by
thoracentesis. As the condition advances to the fibrinopurulent stage, the fluid becomes
more viscous due to fibrin deposition, often necessitating chest tube placement or adjunc-
tive therapies such as tissue plasminogen activator (rTPA)/DNAse to facilitate drainage.
In the organizing phase, where fibrous septations form, chest tube drainage alone may
J. Clin. Med. 2024, 13, 6331 9 of 18

be insufficient, and additional interventions like medical thoracoscopy, VATS, or open

decortication might be required [39,40].
The effectiveness of chest tube drainage is influenced by several factors, including
the size and location of the effusion, the viscosity of the pleural fluid, and the presence
of loculations. Consequently, careful patient selection and technique are paramount [41].
LBCTs of 20–28 French were generally preferred for their superior drainage capabilities
in thick, purulent effusions. However, small-bore catheters (10–14 French) have gained
popularity due to their less invasive nature and comparable efficacy in certain scenarios,
particularly when combined with rTPA/DNAse therapy [42,43].
In addition to mechanical drainage, the role of intrapleural fibrinolytics and enzymatic
debridement has been increasingly recognized, especially when simple drainage fails
and the patient is not suitable for surgery. Agents such as rTPA combined with DNase
can enhance drainage efficacy by breaking down fibrinous septations and reducing fluid
viscosity, thereby improving outcomes in patients with loculated effusions [38].

4.3. Hemothorax
Pleural drainage, specifically the use of chest tubes, plays a critical role in the manage-
ment of hemothorax, which is the accumulation of blood in the pleural cavity. The primary
objectives of pleural drainage in hemothorax are to evacuate the blood, restore normal
respiratory function, prevent clot formation, monitor for ongoing bleeding, and prevent
long-term complications such as fibrothorax [44].
Hemothorax often results from traumatic injury, surgical complications, or sponta-
neous causes such as rupture of blood vessels in the pleura. Conservative treatment of
occult hemothorax fails in over one patient out of five, and the presence of hemothorax
greater than 300 mL and the need for mechanical ventilation predict the failure of conser-
vative treatment and the need for a thoracostomy tube [45]. Immediate pleural drainage
is essential to mitigate the risk of respiratory distress and to facilitate lung re-expansion.
The placement of 28–32 French LBCTs has been historically recommended for initial man-
agement to ensure the effective evacuation of blood and clots. Recent evidence suggests
that 14 Fr percutaneous pig-tail catheters can be equally as effective as 28–32 Fr tubes in
patients with traumatic hemothorax or hemopneumothorax, resulting in reduced patient
discomfort during and after insertion [46].
The initial volume of blood drained can provide crucial diagnostic information.
Drainage of more than 1500 mL of blood upon chest tube insertion, or continued bleeding
of more than 200 mL per hour over 2–4 h, often indicates the need for surgical intervention,
such as thoracotomy, to control the source of bleeding. Moreover, in cases of retained
hemothorax, where clotted blood remains in the pleural space despite initial drainage, early
VATS has been shown to be effective. VATS allows for the direct visualization and removal
of clots, reducing the risk of infection and fibrothorax [47].
The management of hemothorax with pleural drainage is associated with a significant
reduction in morbidity and mortality when promptly and appropriately administered.
Recent studies highlight the importance of early intervention and the use of adjunctive tech-
niques such as VATS or thrombolytic therapy (tPA and DNase) in cases where conventional
drainage fails to evacuate the hemothorax completely [48–50]. These advancements un-
derline the evolving landscape of hemothorax management and the critical role of pleural
drainage in improving patient outcomes.

4.4. Pneumothorax
Pneumothorax, characterized by the presence of air in the pleural cavity, can be clas-
sified as spontaneous or traumatic. Spontaneous pneumothorax can in turn be primary
(occurring without any apparent underlying lung disease) or secondary (associated with
pre-existing lung pathology). It has been suggested, though, that many patients with pri-
mary spontaneous pneumothorax actually have emphysema-like changes/pleural porosity
J. Clin. Med. 2024, 13, 6331 10 of 18

that has not been identified by chest imaging, and the distinction between primary and
secondary pneumothorax may not be as important [51].
Primary spontaneous pneumothorax (PSP) typically affects young, healthy individuals.
It often results from the rupture of subpleural blebs or bullae, which are more common in
tall, thin, young men. The most common causes of secondary spontaneous pneumothorax
(SSP) are chronic obstructive pulmonary disease (COPD), cystic fibrosis, lung malignancy,
or infections. These conditions compromise alveolar integrity, leading to air leakage into
the pleural space. Traumatic pneumothorax results from blunt or penetrating chest injury
(e.g., rib fractures, stab wounds). Iatrogenic pneumothorax is a subtype caused by medical
procedures such as lung biopsies or central venous catheter placements.
Pneumothorax often requires chest tube placement for the evacuation of air and
re-expansion of the lung (Table 1), while needle aspiration may be sufficient for small
pneumothoraces. Chest tube insertion is highly effective in managing PSP. Success rates for
lung re-expansion are high, typically around 80–90%. However, recurrence rates can be
significant, with 23–50% of patients experiencing another episode.
In the last decade, the choice of whether to drain a PSP was mainly made based on the
distance > 2 cm between the lung and the chest wall at the hilum (or 3 cm at the apices) on a
posteroanterior chest X-ray [52]. However, many experts are adopting a more conservative
approach in selected cases [24].
A recent randomized controlled study showed that 94% of patients with large but
minimally symptomatic PSP treated conservatively achieved complete re-expansion within
8 weeks. The enrolled subjects had an SPS size ≥ 32%, corresponding to the sum of
interpleural distances > 6 cm on an erect posteroanterior chest X-ray, according to the
Collins method [53]. The success achieved with drainage was 98% but the difference
was not statistically significant. Furthermore, patients treated conservatively experienced
significantly lower rates of 12-month recurrence (8.8% versus 16.8% of patients undergoing
thoracic drainage) [54].
Accordingly, the most recent British Thoracic Society (BTS) guideline for pleural
disease emphasized that asymptomatic or minimally symptomatic patients with PSP pneu-
mothorax may be managed conservatively without immediate invasive procedures [11,55].
In SSP, chest tube insertion is crucial due to potentially large and prolonged air leaks,
and the increased risk of morbidity and mortality. Success rates are lower compared to
PSP due to the underlying lung pathology. Persistent air leaks are more common, and
additional interventions such as surgery or chemical pleurodesis may be required. In
the presence of high surgical risk, maintaining the tube for a long time may be the only
way to allow continuous evacuation of air from the pleural cavity and prevent tension
pneumothorax [56].
Chest tube insertion is critical in managing traumatic pneumothorax, particularly
when bilateral, when there is associated hemothorax or large air leaks. The management of
pneumothorax has seen significant advances with the introduction of portable long-term
air leak devices. These devices allow for safe and effective outpatient treatment, reducing
hospital stays and healthcare costs while providing continuous monitoring of pleural air
leaks. Moreover, they offer patients greater mobility and quality of life during the recovery
process, making them an essential option in the management of both spontaneous and
post-surgical pneumothorax [57].
Tension pneumothorax is an emergency condition where immediate chest tube inser-
tion can be lifesaving by relieving pressure on the mediastinum and restoring cardiovascu-
lar stability.

5. Measures for Appropriate Chest Tube Placement

5.1. Insertion Site
Chest X-rays and computed tomography (CT) scans provide essential information
for the diagnostic workup of pleural diseases that may require a chest drain. Thoracic
ultrasound (TUS) has become the method of choice to define the indication for the procedure
J. Clin. Med. 2024, 13, 6331 11 of 18

and choose the type of chest tube and the insertion site. Imaging examinations should
always precede the placement of a chest tube unless the situation’s urgency and the setting
do not allow it (for example, in the case of tension pneumothorax, especially in an out-of-
hospital setting).
In adults, the fourth or fifth intercostal space (approximately at the level of the nipple
in men) along the midaxillary line is commonly used as the chest tube insertion site to drain
a pleural effusion. This corresponds to the “safe triangle” area, posterior to the pectoralis
major muscle, and anterior to the latissimus dorsi muscle [58]. An incision 1 cm anterior
to the midaxillary line appears to reduce the risk of damaging the peripheral nerves of
the lateral thoracic wall [59]. Loculated pleural effusion may require different insertion
positions, identified by ultrasound. Apical pneumothorax and tension pneumothorax
are often drained through the second or third intercostal space at the midclavicular line.
However, this site may be uncomfortable for the patient and leave an unsightly scar, so it
should not be the first choice [60].
Occasionally two simultaneous or consecutive chest tubes may be necessary to ef-
fectively drain non-communicating infected fluid collections after attempted intrapleural
fibrinolytics/DNAse. It is common practice to insert the chest tube using the so-called
freehand technique, in which the doctor marks the entry point under ultrasound guidance
and then performs the procedure immediately afterward without moving the patient.

5.2. Chest Tube Insertion Techniques

In most circumstances, nowadays chest drainage is performed at the patient’s bedside.
Except for penetrating chest injuries, prophylactic administration of antibiotics ahead
of chest tube placement is not required [61]. SBCTs can be inserted using the Seldinger
technique, also known as the guidewire technique, or through an atraumatic stylet that
introduces the drain in the pleural space without needing a guidewire. Modern kits for
inserting SBCT have a Verres-type needle and an inner stylet with a dull tip to protect
the lungs from injury. During insertion, the stylet’s blunt tip is pushed into the needle,
exposing the cutting profile. After the needle reaches the pleural cavity, a spring pushes
the atraumatic tip out to its previous position. These are the most widespread methods
due to the ease of insertion and increased patient comfort [62].
The trocar technique consists of introducing the tube thoracostomy together with a
trocar into the pleural space using strength. Its use is decreasing due to the greater risk of
damaging the surrounding tissue, including blood vessels and lung parenchyma, leading to
complications such as hemorrhage or lung injury. Thus, the authors would not recommend
the use of the trocar. Blunt dissection, on the other hand, allows for a controlled and gradual
separation of tissue layers, minimizing trauma. Unlike the guide wire technique, which
is better suited for smaller bore catheters, blunt dissection ensures the safer placement of
large-bore tubes in cases of significant pleural effusions or pneumothorax requiring rapid
drainage [63].
To place a chest tube, the patient usually lies in the lateral or supine recumbent
position. Once the intercostal space has been chosen, the skin must be disinfected and
local anesthesia (usually Lidocaine) administered to the insertion site, up to the deeper
tissues. Placement of the chest tube over an area of skin affected by infection or tumor
infiltration should be avoided. The needle goes over the upper edge of the rib to reduce
the risk of damage to the neurovascular bundle. Aspiration into the syrinx of air bubbles
(in pneumothorax) or fluid (in pleural effusions) confirms that the needle has reached the
pleural space. A small incision in the skin facilitates the introduction of the catheter [64].
To insert LBCTs, a blunt dissection is needed to reach the pleural space.
The tube should be directed posteriorly and downwards to drain a pleural effusion or
toward the front and upward to remove air in pneumothorax. Once the tube is placed, it is
sutured in place and connected to a drainage system with an underwater seal or suction.
J. Clin. Med. 2024, 13, 6331 12 of 18

5.3. Securing the Chest Tube

Anchoring a chest tube is essential to ensure its proper function and to prevent
infections and dislodgement [65]. There is evidence that suturing chest tubes can lower the
rates of their unintentional dislodgment outside the pleural cavity before a clinical decision
to remove the drain (6.6% versus 14.8% of non-sutured drains) [66].
Figures 3 and 4 show the most common methods for anchoring a pleural drain and
the progressive steps to secure a large-bore chest tube using the purse-string technique. A
J. Clin. Med. 2024, 13, x FOR PEER REVIEW 14 of 19
recent multicenter trial compared a ballooned 12 Fr intercostal drain to a similarly
J. Clin. Med. 2024, 13, x FOR PEER REVIEW 14 sized
of 19
tube secured with a single suture. The balloon integrated into the drain works like a
bladder catheter which can be inflated with sterile water when it lies inside the pleural
movement
movement and
and the
space to prevent theit risk
from
risk of dislodgement.
ofslipping Usually,
out [67].
dislodgement. number
The analyses
Usually, numberof 11 or 00 silk
silk sutures
displacement
or sutures are
rate used
used for
areshowed fora
large
trend bore tubes,
favorable and
to 00 for
ballooned small bore
drain, tubes.
although When
not the incision
statistically has left
significant space
(3.9%
large bore tubes, and 00 for small bore tubes. When the incision has left space next to the next
vs. to the
10.1%).
The control
drain,
drain, group’s
aa second
second suture
suturedisplacement
may
may be rate wasto
be necessary
necessary less
to than expected
prevent
prevent the in real-life
the passage
passage of practice,
of liquid
liquid or air.probably
or air. The
The re-re-
due partially
taining stitchesto the
are high
commonlydegree of utilization
maintained of
10–15 ultrasound
days after during
removing
taining stitches are commonly maintained 10–15 days after removing the chest tube. the study.
the chest tube.

Different methods for

Figure 3. Different
Figure for anchoring aa pleural
pleural drain. (A):
(A): Simple stitch
stitch and Roman
Roman sandal
Figure 3.3. Different methods
methods for anchoring
anchoring a pleural drain.
drain. (A): Simple
Simple stitch andand Roman sandalsandal
technique
technique in a small-bore chest tube; (B): Simple stitch and tie of the drainage tube; (C): Purse-string
technique in in aa small-bore
small-bore chest
chest tube;
tube; (B):
(B): Simple
Simple stitch
stitch and
and tie
tie of
of the
the drainage
drainage tube;
tube; (C):
(C): Purse-string
Purse-string
sutures
sutures in
sutures in aaa large-bore
in large-bore chest
large-bore chest tube;
chest tube; and
tube; and (D):
and (D): Indwelling
(D): Indwelling pleural
Indwelling pleural catheter
pleural catheter (IPC)
catheter (IPC) secured
(IPC) secured by
secured by two
by two simple
two simple
simple
stitches and
stitches and
stitches a Roman
and aa Roman sandal
Roman sandal at
sandal at the
at the proximal
the proximal end.
proximal end.
end.

Figure
Figure 4.
Figure 4. Progressive
4. Progressive steps
Progressive steps (from
steps(from A–F)
A–F)toto
(fromA–F) secure
tosecure aa large-bore
a large-bore
secure chest
chest
large-bore tubetube
chest using
using
tube the
the purse-string
the purse-string
using technique.
purse-string
technique.
technique.

6.
6. Complications
Complications and
and Management
Management
Despite
Despite advancements, chest
advancements, chest tube
tube placement
placement is
is not
not without
without risks.
risks. Complications
Complications in-in-
clude
clude tube malposition, infection, bleeding, organ injury, and re-expansion pulmonary
tube malposition, infection, bleeding, organ injury, and re-expansion pulmonary
edema.
edema. Preventative
Preventative measures
measures and
and prompt
prompt management
management of of complications
complications are
are critical.
critical. Ta-
Ta-
J. Clin. Med. 2024, 13, 6331 13 of 18

The simple Donati stitch (horizontal mattress suture) uses a large-bore needle to place
a suture through the skin, around the chest tube insertion site, and out through the skin
again, forming a figure-of-eight or mattress suture.
In the purse-string suture technique, a suture is placed circularly around the chest tube
insertion site. When tied, it cinches the tissue around the tube.
The Roman sandal technique is a common strategy to reduce dislodgement risk.
The suture thread is placed around the tube, crisscrossed, and tied in a manner
resembling a Roman sandal’s lacing.
Tube securement devices, which adhere to the skin and grip the tube, providing an
alternative to sutures, are commercially available. They offer a quick and often more
comfortable way to secure the chest tube, with less risk of skin irritation and infection.
Finally, sterile adhesive dressings and tapes are used to anchor the tube to the chest
wall. They reinforce the stability provided by sutures or securement devices, reducing
movement and the risk of dislodgement. Usually, number 1 or 0 silk sutures are used for
large bore tubes, and 00 for small bore tubes. When the incision has left space next to
the drain, a second suture may be necessary to prevent the passage of liquid or air. The
retaining stitches are commonly maintained 10–15 days after removing the chest tube.

6. Complications and Management

Despite advancements, chest tube placement is not without risks. Complications
include tube malposition, infection, bleeding, organ injury, and re-expansion pulmonary
edema. Preventative measures and prompt management of complications are critical.
Table 3 shows the key complications that may arise during chest tube placement and
provides succinct management strategies for each.

Table 3. Potential complications during chest tube insertion and their management.

Complication Description Management

Tube placed outside the pleural space or in an Immediate imaging (US/X-ray/CT)
Malposition
incorrect position Repositioning or replacement
Aseptic technique
Pleural cavity or insertion site infection. The risk is Antibiotics if signs of infection
Infection
higher for long-term chest tubes. Check for the appearance of pus or
laboratory signs of infection
Apply direct pressure
Bleeding Injury to intercostal vessels or lung parenchyma
Surgical consultation if severe
Limit drainage frequency
Re-expansion Rapid lung re-expansion after drainage of large
Provide oxygen
Pulmonary Edema effusions/pneumothorax
Diuretics if needed
Clamp test to locate leak Surgical
Persistent Air Leak Continuous air bubbling indicating air leak
consultation if persistent
Ensure proper tube placement
Subcutaneous Emphysema Air leakage into subcutaneous tissues
Adopt suction or repositioning tube
Blockage of the chest tube (e.g., clots, fibrin, Flush or replace tube
Tube Occlusion
thick fluid) Monitor output closely

6.1. Preventative Measures

Rigorous adherence to sterile procedures minimizes the risk of infection, which is cru-
cial given the direct access to the pleural space and the potential introduction of pathogens.
This includes the use of full barrier precautions, proper skin antisepsis, and the sterile
handling of equipment throughout the procedure. Ensuring that clinicians are adequately
trained in both the technical and anatomical aspects of chest tube placement significantly re-
duces the risk of complications. This training should encompass a thorough understanding
of chest wall anatomy, appropriate site selection for tube insertion, and the proper technique
J. Clin. Med. 2024, 13, 6331 14 of 18

for securing and maintaining the chest tube. Furthermore, using imaging guidance such as
ultrasound during insertion can enhance accuracy and safety. Regular competency assess-
ments and continuing education help maintain high standards of practice. Additionally,
the use of protocols and checklists can standardize procedures and reduce the likelihood of
errors, contributing to improved patient outcomes and reduced complication rates [68].

6.2. Management of Complications

Chest tube management also involves meticulous care to prevent complications such as
tube dislodgment, infection, and re-expansion pulmonary edema. Awareness of anatomical
landmarks and the use of imaging guidance can reduce the risk of injuring the lung,
diaphragm, or abdominal organs. Misplaced tubes may require repositioning (i.e., partial
withdrawal) or replacement, often guided by imaging techniques. Antibiotic prophylaxis
may be warranted in certain high-risk scenarios, and any signs of infection should prompt
immediate evaluation and treatment. Regular monitoring of output, fluid characteristics,
and imaging studies are essential to guide ongoing management and to determine the
appropriate timing for tube removal. Moreover, when chest tubes are used to drain pus and
other infectious materials, the viscosity of the fluid and the potential presence of fibrinous
materials can increase the risk of occlusion. To prevent the blockage of drainage, as well as
to cleanse the pleural cavity, continuous or intermittent flushing is recommended [19].

6.3. Training, Learning, and Practicing Chest Tube Management

Acquiring the skills and undergoing training to place and manage a chest tube is a
multifaceted process that combines theoretical knowledge, simulation-based practice, and
clinical experience. Initially, trainees should understand the indications, contraindications,
and anatomical considerations of chest tube insertion. Comprehensive knowledge of
pleural anatomy and pathophysiology is essential, as it underpins the decision-making
process and procedural steps involved in chest tube placement. Theoretical learning is
often supported by detailed guidelines and instructional videos.
Simulation-based training plays a critical role in skill acquisition, providing a risk-free
environment for trainees to practice the insertion technique [69]. High-fidelity dummies
and virtual reality simulators allow for repeated practice of needle insertion, guidewire
manipulation, and catheter placement, helping trainees develop muscle memory and
procedural confidence. Simulation also includes the use of bedside ultrasound, which is
crucial for guiding the procedure and reducing complications such as organ puncture.
Hands-on clinical training, supervised by experienced physicians, is essential for
translating simulation skills into real-world competence. During clinical rotations, trainees
perform chest tube insertions on patients under direct supervision, receiving immediate
feedback and guidance. This practical experience is invaluable for learning to manage
complications, make quick and accurate decisions, and ensure patient safety.
Ongoing assessment and continuous professional development are integral to main-
taining proficiency in chest tube management. Regular workshops, peer discussions, and
advanced training courses help clinicians stay updated with the latest techniques and best
practices. By integrating comprehensive theoretical education, hands-on practice, and
continuous learning, clinicians are equipped to perform chest tube insertions safely and
effectively, thereby improving patient outcomes in the management of pleural diseases.
A recent study investigated the state of training and experience among UK medical
higher specialty trainees (HSTs) in performing Seldinger chest tube insertions in acute
care settings [70]. The authors found that non-respiratory trainees had fewer procedures,
and lower confidence and knowledge, posing a training and service delivery challenge
with significant patient safety implications. Addressing these gaps is crucial for improving
outcomes in pleural disease management.
J. Clin. Med. 2024, 13, 6331 15 of 18

7. Conclusions
Chest tube thoracostomy and pleural drainage remain cornerstone interventions in
the management of pleural effusion and pneumothorax. The evolution from ancient
techniques to modern, sophisticated systems underscores the importance of continuous
innovation and education in this field. Recent advances include the use of smaller bore
catheters, which are less invasive and have shown similar efficacy to traditional chest tubes
in select patients. Additionally, digital chest drainage systems offer real-time monitoring
of intrapleural pressures and air leaks, enhancing clinical decision-making. Ongoing
research and technological advancements hold the promise of further improving the efficacy
and safety of these critical procedures, ultimately enhancing patient outcomes in pleural
disease management.

Author Contributions: Conceptualization, C.S., N.M.R. and D.F.-K.; methodology, C.S. and D.F.-K.;
writing—original draft preparation, C.S., F.M., S.A., G.M. and M.M.; supervision, C.S., D.F.-K. and
N.M.R. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Data Availability Statement: No new data were created or analyzed in this study. Data sharing is
not applicable to this article.
Conflicts of Interest: The authors declare no conflicts of interest.

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