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See Critical Care Chapter 3.


  • Indications: 1) Diagnostic for pleural effusion of unknown cause; 2) Therapeutic for respiratory symptoms due to large effusions

  • Tests to consider:

    • - Pleural fluid protein and LDH (for Light’s criteria)

    • - Cell count and differential (PMN predominance suggests an acute process such as a parapneumonic effusion or PE; mononuclear predominance suggests cancer or TB)

    • - Gram stain and culture

    • - Hct (1–20% suggests cancer, PE, trauma; >50% suggests hemothorax)

    • - Glucose (<60 mg/dL suggests parapneumonic effusion or empyema, cancer, or possibly TB, RA, SLE, or esophageal rupture)

    • - Cytology

    • - pH (can be helpful to diagnose parapneumonic effusion or empyema since pH <7.2 in most cases)

    • - Triglycerides (>100 mg/dL suggests chylothorax)

    • - Amylase (level may be elevated if pleural effusion due to pancreatic disease, esophageal rupture)

  • Relative contraindications: 1) Coagulopathy/thrombocytopenia (especially DIC), 2) Overlying cellulitis, 3) Inability to tolerate a potential complication (e.g., if patient only has one functional lung at the time)

  • Complications:

    • - Pneumothorax: Rare. Even when present, rarely requires the placement of a chest tube. Obtain post-procedure CXR if air was aspirated during the procedure, if the patient develops chest pain, dyspnea, or hypoxia, if there were multiple needle passes during the procedure, or if the patient is critically ill and/or receiving mechanical ventilation.

    • - Other: Minor: Pain, coughing, localized infection. Severe: Hemothorax, intraabdominal organ injury, air embolism, and postexpansion pulmonary edema (although this is rare, increasingly controversial, and can probably be avoided by limiting therapeutic aspirations to <1500 mL).


  • Description: Flexible plastic tube placed into the pleural space (or mediastinum) through the chest wall for drainage of air, fluid, or pus

  • Indications:

    • - Air (tension pneumothorax)

    • - Fluid (hemothorax, persistent effusion; do NOT put in for hepatohydrothorax)

    • - Pus (empyema)

  • Components: Three-bottle system (Figure 2.14)

    • - Collection trap – Tubes on right side

    • - Water seal (gradient to flow out) – Look for air leak in form of bubbles

    • - Suction to wall (with suction regulator) – Normal to see bubbles

  • Parameters to report on rounds:

    • - Suction Is the tube on water seal or suction? If on suction, at what pressure (measured in cm H2O)?

    • - Volume: How much has the chest tube drained? What is the rate of drainage and is it increasing/decreasing?

    • - Quality: What color is the fluid that has drained?

    • - Air leak: Is there an air leak?


The chest tube: A “three-bottle” system. A chest tube uses a three bottle system for fluid collection, forming a water seal, and controlling suction.



Respiratory treatments by inhaler class.

Source: Allergy & Asthma Networks.

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