Pleural controversy: Optimal chest tube size for drainage

In recent years, a higher and higher percentage of patients with pleural effusions or pneumothorax are being treated with small‐bore (10–14 F) chest tubes rather than large‐bore (>20 F). However, there are very few randomized controlled studies comparing the efficacy and complication rates with the small‐ and large‐bore catheters. Moreover, the randomized trials that are available have flaws in their design. The advantages of the small‐bore catheters are that they are easier to insert and there is less pain with their insertion while they are in place. The placement of the small‐bore catheters is probably more optimal when placement is done with ultrasound guidance. Small‐bore chest tubes are recommended when pleurodesis is performed. The success of the small‐bore indwelling tunnelled catheters that are left in place for weeks documents that the small‐bore tubes do not commonly become obstructed with fibrin. Patients with complicated parapneumonic effusions are probably best managed with small‐bore catheters even when the pleural fluid is purulent. Patients with haemothorax are best managed with large‐bore catheters because of blood clots and the high volume of pleural fluid. Most patients with pneumothorax can be managed with aspiration or small‐bore chest tubes. If these fail, a large‐bore chest tube may be necessary. Patients on mechanical ventilation with barotrauma induced pneumothoraces are best managed with large‐bore chest tubes.