Gen Thorac Cardiovasc Surg
DOI 10.1007/s11748-016-0646-z
CURRENT TOPICS REVIEW ARTICLE
Management of chest drainage tubes after lung surgery
Yukitoshi Satoh1
Received: 14 March 2016 / Accepted: 29 March 2016
Ó The Japanese Association for Thoracic Surgery 2016
Abstract Since chest tubes have been routinely used to
drain the pleural space, particularly after lung surgery, the
management of chest tubes is considered to be essential for
the thoracic surgeon. The pleural drainage system requires
effective drainage, suction, and water-sealing. Another key
point of chest tube management is that a water seal is
considered to be superior to suction for most air leaks.
Nowadays, the most common pleural drainage device
attached to the chest tube is the three-bottle system. An
electronic chest drainage system has been developed that is
effective in standardizing the postoperative management of
chest tubes. More liberal use of digital drainage devices in
the postoperative management of the pleural space is
warranted. The removal of chest tubes is a common pro-
cedure occurring almost daily in hospitals throughout the
world. Extraction of the tube is usually done at the end of
full inspiration or at the end of full expiration. The tube
removal technique is not as important as how it is done and
the preparation for the procedure. The management of
chest tubes must be based on careful observation, the
patient’s characteristics, and the operative procedures that
had been performed.
Keywords Thoracic surgery
Chest tube
Drainage

Device
Management
& Yukitoshi Satoh
ysatoh@med.kitasato-u.ac.jp
1 Because chest tubes are placed postoperatively in most
Department of Thoracic Surgery, Kitasato University School
of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara,
Kanagawa 252-0374, Japan
Introduction
In general, the indication to insert a chest tube into the
pleural space is the presence of fluid or air in the pleural
space (Table 1) [1]. Moreover, chest tubes have been
routinely used to drain the pleural space, particularly after
lung surgery. Chest tubes are known to have a long his-
tory of clinical use. Gotthard Bülau was considered the
originator of the first closed water seal drainage system as
early as 1875 [1, 2]. Then in the early twentieth century, a
closed pleural space drainage system became the standard
of care, and the concept of underwater seal had been
established [1].
The management of chest tubes is essential for thoracic
surgeons as a well-protected bastion of their profession [1].
When most chest surgeries finish, chest tubes should
always be inserted. Thereafter, we should manage the tube
settings and daily clinical observation, decide when and
how to remove them, and manage the pleural space par-
ticularly after that. However, it is well known that thoracic
procedures are quite heterogeneous and postsurgical
requirements vary in accordance.
In this review, I would like to refer to mechanism of
suction system including new devices, chest tube man-
agement, how to remove a chest tube, and also new suction
devices particularly after thoracic surgery.
Mechanism of suction system
Development of drainage devices
patients who had undergone thoracic surgery to prevent
pneumothorax and to monitor for air leak and
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Table 1 Indication for chest tube drainage
Pneumothorax
Spontaneous (primary, secondary)
Other pneumothorax
Tension pneumothorax
Traumatic
Iatrogenic
Hemothorax
Empyema
Parapneumonic effusions
Frank empyemas
Pleural effusion
Chylothorax
Postoperative drainage
Thoracic procedures
Cardiac surgery
hemothoraces, the pleural drainage system requires effec-
tive drainage, suction and water-sealing. To attain these
objectives effectively, the development of the pleural
drainage device has an interesting and long story. Finally, it
was arrived at the famed three-bottle system that is com-
monly used these days [1].
Now, chest tubes are available in various sizes and
types. Despite the long evolution of the development for
chest tube usage and its placement, and it becoming one of
the most common procedures in managing patients with
pleural disease, there are scant reports and few data to
support the sizes and shapes of tube. Recently, however,
several prospective randomized studies had been com-
pleted, and they have evidenced some of the problems of
alveolar-pleural fistulas and management for air leaks [3–
5]. At least, many surgeons use soft, pliable tubes that are
large enough so as not to clot and will likely cause less pain
[1].
Another clinical question addressed was ‘Should we
place one or two chest drains in patients undergoing
lobectomy?’ According to numerous studies in this area, no
differences in the duration or amount of drainage, or the
length of hospital stay could be demonstrated with any
significance [6]. Therefore, the use of the two-drain method
is not superior to the one-drain method, and may likely
cause more pain, and could obviously be more expensive.
The closed drainage system
Initially, a one-bottle system was used for drainage, how-
ever, as the fluid or blood that drained from the patient rose
in the bottle, it increased the resistance to further drainage
[1]. Eventually, the most basic chest drainage system unit
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Gen Thorac Cardiovasc Surg
is the three-bottle system. In this system, the first bottle is
used to collect fluid or blood from patients, the second
bottle provides a water seal condition, and the third regu-
lates the amount of suction applied through the entire
system [1]. In the past, when it became evident that an
active suction system led to the best design, several com-
panies began to develop ways to combine all three bottles
into one compact type. Consequently, commercial systems
worldwide use this technology today.
The digital chest drainage system
Recently, several companies have manufactured and
commercialized new pleural drainage units. Some investi-
gations have shown that electronic chest drainage systems
are effective in standardizing the postoperative manage-
ment of chest tubes: DigiVentÒ (Millicore, Sweden) and
Thopaz (MedelaÒ Baar, Switzerland) [7, 8]. Particularly,
the Thopaz system is a portable suction unit which allows
patients’ mobilization with digital recordings for air flow
and fluid. A multicenter international randomized clinical
trial showed that patients managed with this type of digital
drainage system experienced shorter air leak duration,
shorter duration of chest tube placement and hospital stay,
and higher satisfaction scores compared with patients
managed with traditional devices [7]. Contrastingly, Gil-
bert et al. [9] described that digital devices decreased tube
clamping trials, but the impact on duration of chest tube
drainage and hospital stay was not statistically significant.
It is, however, considered that novel digital drainage
systems markedly reduce interobserver variability in air
leak assessment and may thus shorten chest tube duration
and overall hospital stay. These findings appeared to be
consistent across different healthcare systems and coun-
tries. Although these results need to be confirmed by other
independent investigations, and more sophisticated analy-
ses are needed to clarify the influence of regulated pressure
on duration of air leak, a more liberal use of digital drai-
nage devices in the postoperative management of pleural
space appears warranted [7].
Chest tube management
Despite the long history of clinical use, the management of
chest tubes has been mainly an art but uncompleted form
without the application of evidence-based medicine [1]. Air
leaks, alveolar-pleural fistulas, and hemorrhage are the
most common complications after lung resection. Once the
chest tube is inserted after surgery, we should manage it
based on scientific data. Recently, Brunelli et al. [10], Refai
et al. [11], and Cerfolio and Bryant [12] have performed
many studies that have scientifically evaluated the optimal
Gen Thorac Cardiovasc Surg
manner to manage chest tubes after pulmonary resec-
tion. The basic import of these studies has been to provide
objective data to guide the management of chest tubes after
pulmonary resection.
Another key point of chest tube management is that the
water seal is considered to be superior to continuous
suction for most air leaks [5]. In contrast to that, Coughlin
et al. [13] showed no significant differences in terms of
duration of air leak, incidence of prolonged air leak,
duration of chest tubes, and duration of hospital stay
when chest tubes were placed to suction rather than water
seal by a systematic review and meta-analysis. They
concluded that chest tube suction appears to be superior
to water seal in reducing the incidence of pneumothorax;
however, the clinical significance of this finding is unclear
[13]. However, the most common clinical setting for the
occurrence of air leaks should be after pulmonary resec-
tion. Moreover, Antanavicius et al. [14] demonstrated that
in patients without air leak, chest tubes should be man-
aged with water seal following anatomical pulmonary
resection, resulting in significantly shorter chest tube
duration and hospital stay.
How to remove a chest tube
When and how do we remove chest tubes? Many surgeons
use unnecessary strict criteria for the amount of drainage.
Generally in Japan, the criterion of about 200 ml/day of
fluid is the cutoff point for removal of a chest tube with no
air leak. But air leaks are not the most common limiting
factor that prevents tubes from being removed.
The physician should be certain that the chest tube is
ready to taken out before removing it. The removal of chest
tubes is a commonly performed procedure that occurs
almost every day in hospitals. It is performed most com-
monly either at the end of full inspiration or at the end of
full expiration. Recent study by Cerfolio et al. [15] showed
that removal of chest tubes after pulmonary resection at the
end of expiration leads to a lower incidence of non-clini-
cally significant pneumothorax than at the end of inspira-
tion. Because of these findings, the study was closed early,
and it was considered as being underpowered for finding a
statistically significant difference in the rare (1–3 %)
clinically significant pneumothoraces. Another study on
chest tube removal after trauma by Bell et al. [16] revealed
that discontinuation of chest tubes at the end of inspiration
or at the end of expiration has a similar rate of post-re-
moval pneumothorax. They concluded that both methods
were equally safe [16]. Therefore, the tube removal tech-
nique chosen is not as important as the way in which it is
done and the preparation. Generally, either technique is
considered as safe [12].
Conclusions
It is well known that the insertion, management, and
removal of chest drainage tubes should not be taken lightly.
The management of chest tubes needs to be based on
careful observation clinically and should take into account
patient characteristics and the operative procedures per-
formed. In the near future, a more use of digital devices in
the postoperative management of pleural space will likely
be warranted, and evidence-based management of chest
tubes becomes gold standard throughout the world.
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