Chest Tube Recommendations for Pneumothorax Based on Size

Primary Pneumothorax Management

For primary pneumothoraces, simple aspiration should be attempted first if the pneumothorax is <2 cm and the patient is clinically stable 1
Large primary pneumothoraces (>2 cm) should be managed with chest tube drainage if simple aspiration fails 1
Small primary pneumothoraces (<1 cm or apical) in stable, non-breathless patients can be observed without chest tube placement 1
Repeat aspiration is reasonable when first aspiration is unsuccessful and <2.5 L has been aspirated on the first attempt 1

Intercostal tube drainage is recommended for secondary pneumothoraces except in patients who are not breathless and have a very small (<1 cm or apical) pneumothorax 1
Large secondary pneumothoraces (>2 cm), particularly in patients over 50 years old, have a high risk of failure with simple aspiration and should be treated with tube drainage as initial treatment 1
Patients with secondary pneumothoraces who undergo simple aspiration should be admitted for observation for at least 24 hours 1

Small-bore tubes (10-14F) are recommended as initial treatment for pneumothoraces 3
There is no evidence that large tubes (20-24F) are better than small tubes (10-14F) in managing pneumothoraces 3
For unstable patients or those requiring mechanical ventilation with large pneumothorax, larger tubes (24F-28F) may be appropriate 2
Factors that might favor larger tube selection include presence of pleural fluid and large air leaks that exceed the capacity of smaller tubes 3

Pneumothoraces that fail to respond within 48 hours to treatment should be referred to a respiratory physician 4
For patients with cystic fibrosis, chest tube placement is recommended for large pneumothoraces regardless of clinical stability 5
For patients with cystic fibrosis with small pneumothoraces, chest tube placement is only recommended if there is clinical instability 5
Pleurodesis should not be performed for first pneumothorax but should be considered for recurrent large pneumothoraces 5

Tube blockage is more common with small-bore tubes, which may necessitate replacement with a larger tube if there is a persistent air leak 3

Failure of a pneumothorax to re-expand or a persistent air leak exceeding 48 hours should prompt referral to a respiratory physician 4
All chest tubes should be connected to an appropriate drainage system, such as a water seal device (with or without suction) or a Heimlich valve 2