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Background:
Review

Comprehensive Overview of Current Pleural Drainage Practice: A Tactical Guide for Surgeons and Clinicians

by
Paolo Albino Ferrari
1,2,*,†,
Cosimo Bruno Salis
3,†,
Elisabetta Pusceddu
4,
Massimiliano Santoru
1,2,
Gianluca Canu
5,
Antonio Ferrari
6,
Alessandro Giuseppe Fois
7,‡ and
Antonio Maccio
2,8,‡
1
Division of Thoracic Surgery, Azienda di Rilievo Nazionale ed Alta Specializzazione “G. Brotzu”, Piazza A. Ricchi 1, 09121 Cagliari, Italy
2
Department of Oncological Surgery, Azienda di Rilievo Nazionale ed Alta Specializzazione “G. Brotzu”, Piazza A. Ricchi 1, 09121 Cagliari, Italy
3
Department of Medicine, Surgery and Pharmacology, University of Sassari, Viale San Pietro 43a, 07100 Sassari, Italy
4
Anesthesia and Intensive Care Unit, Liver Transplantation Center, Azienda di Rilievo Nazionale ed Alta Specializzazione “G. Brotzu”, Via Piazza A. Ricchi 1, 09121 Cagliari, Italy
5
Thoracic Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public-Health, Padua University Hospital, Via Nicolò Giustiniani 2, 35128 Padua, Italy
6
Neuroradiology and Vascular Radiology Unit, Azienda di Rilievo Nazionale ed Alta Specializzazione “G. Brotzu”, Piazza A. Ricchi 1, 09121 Cagliari, Italy
7
Clinical and Interventional Respiratory Unit, University Hospital of Sassari (AOU), 07100 Sassari, Italy
8
Department of Surgical Sciences, University of Cagliari, SS. 554, km 4500, 09042 Monserrato, Italy
*
Author to whom correspondence should be addressed.
†
These authors contributed equally to this work and share first authorship.
‡
These authors contributed equally to this work and share last authorship.
Surgeries 2025, 6(4), 108; https://doi.org/10.3390/surgeries6040108
Submission received: 25 September 2025 / Revised: 15 November 2025 / Accepted: 25 November 2025 / Published: 2 December 2025
Review Reports Versions Notes

Abstract

Introduction: Chest drainage is central to thoracic surgery, pleural medicine, and emergency care, yet practice remains heterogeneous in tube caliber, access, suction, device selection, and removal thresholds. This narrative review aims to synthesize evidence and translate it into guidance. Materials and Methods: We performed a narrative review with PRISMA-modeled transparency. Using backward citation from recent comprehensive overviews, we included randomized trials, meta-analyses, guidelines/consensus statements, and high-quality observational studies. We extracted data on indications, technique, tube size, analog versus digital drainage, suction versus water-seal drainage, removal criteria, and key pleural conditions. Due to heterogeneity in device generations, suction targets, and outcomes, we synthesized the findings qualitatively according to converged evidence. Results: After lung resection, single-drain strategies, early use of water-seal, and standardized removal at ≤300–500 mL/day reduce pain and length of stay without increasing the need for reintervention; digital systems support objective removal using sustained low-flow thresholds (approximately 20–40 mL/min). Small-bore (≤14 Fr) Seldinger catheters perform comparably to larger tubes for secondary and primary pneumothorax and enable ambulatory pathways. In trauma, small-bore approaches can match large-bore drainage in stable patients when paired with surveillance and early escalation of care. For pleural infection, image-guided drainage, combined with fibrinolytics or surgery, is key. Indwelling pleural catheters provide relief comparable to talc in dyspnea associated with malignant effusions in patients with non-expandable lungs. Complications are mitigated by ultrasound guidance and avoiding abrupt high suction after chronic collapse; however, these strategies must be balanced against risks of malposition, occlusion or retained collections, prolonged air leaks, and device complexity, which demand protocolized escalation and team training. Conclusions: Practice coalesces around three pillars—right tube, right system, proper criteria. Adopt standardized pathways, device-agnostic thresholds, and volume or airflow criteria. Trials should harmonize “seal” definitions and validate telemetry-informed removal strategies.

1. Introduction

Chest drainage has been a component of thoracic disease management for millennia, evolving from crude evacuations of “empyemas” in antiquity to standardized surgical tubes, percutaneous catheters, and regulated digital systems that quantify airflow and pleural pressures in real-time [1,2,3].
The Hippocratic corpus described pleural collections and advocated for external drainage of thoracic suppuration, foreshadowing later surgical doctrines that recognized the life-saving effect of restoring negative intrapleural pressure and allowing lung re-expansion [1,4].
Nineteenth-century innovations transformed empirical venting into reproducible, closed systems. William Smoult Playfair’s “closed chest drainage” concept formalized underwater seal principles for safe, continuous evacuation, and Gotthard Bülau popularized water-seal drainage for empyema, with methodical attention to tube positioning and pleural physiology [5,6].
Mass wartime experience in World War I, World War II, and the Korean conflict accelerated the adoption of intercostal drains and standardized postoperative thoracic care, embedding chest tubes as routine adjuncts to thoracotomy and later thoracoscopic surgery [7,8].
Early twentieth-century thoracic surgeons, such as Evarts Ambrose Graham, codified postoperative chest drainage after lung resections, aligning empirical practice with a growing understanding of negative intrapleural pressure and the risks of residual space, atelectasis, and effusion [9].
By the mid-twentieth century, three-bottle systems—collection, water-seal, and suction control—were widely used. At the end of the 1960s, the advent of integrated disposable devices streamlined this setup, consolidating all three components into a single, safer, and more manageable portable drainage unit - in line with the trend of securing thoracostomy drainage to patients - paving the way for modern analog systems [10,11]. In parallel, Henry Heimlich’s one-way valve enabled the ambulatory evacuation of air through small-bore catheters, laying the groundwork for outpatient pneumothorax care and future percutaneous, patient-centric pathways [2,12].
Throughout the late twentieth and early twenty-first centuries, surgical techniques progressed from open thoracotomy to VATS and uniportal approaches. At the same time, catheter technology advanced to include Seldinger-guided placement, softer materials, enhanced kink resistance, and smaller calibers, minimizing tissue trauma and pain without compromising efficacy [13,14].
Contemporary guidance from Enhanced Recovery After Surgery®, European Society of Thoracic Surgery (ERAS, ESTS), and consensus from the Society of Thoracic Surgeons formalized best practices around tube number, size, suction strategy, mobilization, and removal thresholds, encouraging single-drain strategies, selective suction, and early removal in well-defined clinical contexts [15,16]. At the same time, the pleural-medicine and emergency-care communities refined indications and techniques for spontaneous pneumothorax, malignant effusions, pleural infections, and trauma, converging on safety-triangle access, ultrasound guidance, and context-specific choices between small-bore pigtail catheters and larger surgical tubes [17,18,19].
A significant device milestone emerged in 2007 with the introduction of the first widely adopted digital drainage platform, which introduced regulated suction and continuous telemetry of airflow and intrapleural pressure to standardize decision-making and facilitate mobilization and enhanced recovery after lung resection [13,20,21]. Subsequent device generations from multiple manufacturers extended portability, data capture, and alarm functionality, enabling protocols based on quantitative low-flow thresholds (e.g., 20–40 mL/min) rather than subjective bubbling, and supporting safe, earlier removal in selected cohorts [21,22,23].
Across indications, contemporary practice asks the same tactical questions that animated Bülau and Graham—what to drain, where to place the drain, how much suction to apply, and when to remove—now answered with a blend of historical insight, high-level evidence, and digital analytics [6,7,24].
This narrative review synthesizes and interprets primary studies, randomized trials, systematic reviews, and guidelines cited within the most recent comprehensive overviews across thoracic surgery, pleural medicine, and emergency care, aiming to harmonize tube and catheter choices, system settings, and standardized removal criteria for surgeons and clinicians nowdays [15,16,17,18].

2. Materials and Methods

We conducted a targeted narrative review using transparent methods, modeled on the PRISMA guidance for framing questions, identifying sources, and describing selection and synthesis, while acknowledging that clinical heterogeneity precludes data pooling for many device-era questions [25]. No protocol registration or quantitative pooling was performed due to the narrative nature of this review.
We used backward citation (“snowballing”) from index syntheses published up to 2025—thoracic surgery drain management, pleural disease, and emergency medicine procedural practice—to identify randomized controlled trials, meta-analyses, consensus, guidelines, and high-quality comparative cohorts relevant to indications, access and technique, tube size, analogue versus digital systems, suction strategies, and removal criteria [26].
We included adult studies and guidance addressing pneumothorax (primary, secondary, traumatic), hemothorax, postoperative drainage after pulmonary resection, malignant and non-malignant effusions, empyema or complicated parapneumonic effusion, and chylothorax. Pediatric studies were excluded unless they informed safety or device concepts transferable to adults.
We prioritized randomized trials and systematic reviews, meta-analyses, and integrated professional society guidelines for standardizing practice. We used prospective, retrospective cohorts when randomized data were sparse or device generations evolved between trials, explicitly noting equipoise and implications for institutional protocols.
We conducted a qualitative synthesis organized around decision nodes—tube size by indication, analogue versus digital device behavior, suction versus water-seal, and removal thresholds—and highlighted pragmatic algorithms for post-resection, pneumothorax, trauma, malignant effusions, and pleural infection pathways.

3. Preprocedural Evaluation and Indication

3.1. Anatomy, Physiology, and Indications

Pleural drainage restores negative intrathoracic pressure by removing air or liquid that uncouples the visceral and parietal pleura, permitting alveolar re-expansion and improved mechanics of ventilation and perfusion [8,13].
Core indications include primary and secondary spontaneous pneumothorax, traumatic pneumothorax and hemothorax, parapneumonic effusions and empyema, malignant pleural effusions, chylothorax, and routine postoperative management after lung resections [13,17].
Life-threatening tension pneumothorax requires immediate decompression—needle or finger thoracostomy in prehospital or emergency department settings—followed by definitive drainage tailored to the underlying pathology and patient trajectory [17].

3.2. Access Site, Technique, and Safety

Placement at or above the fifth intercostal space within the “triangle of safety” (base of the axilla, lateral edge of pectoralis major, lateral edge of latissimus dorsi, and fifth intercostal space) minimizes risk to the diaphragm and abdominal organs and reduces injury to axillary vasculature and breast parenchyma [18,27]. Traversing the superior rib border preserves the intercostal neurovascular bundle that courses along the inferior rib margin, and structured training/checklists reduce malposition and complication rates [27,28].
Ultrasound refines site selection, detects loculations, confirms intrapleural positioning, and identifies high-risk anatomic variants, with evidence that point-of-care use reduces insertion complications and extrathoracic placement [29,30].
Computed tomography (CT) scan-driven positioning is preferred for complex/multifocal disease, while fluoroscopy may assist when delineating fistulae or guiding exchanges [31].
Open surgical tube thoracostomy relies on incision and blunt dissection to access the pleural space. In contrast, percutaneous pleural catheters utilize Seldinger techniques or an introducer with tract dilation, allowing for smaller-caliber access with reduced procedural pain when the indication permits [14]. Trocar insertion is generally discouraged outside narrow indications due to associations with organ injury and increased complications in contemporary series [32].
Regional anesthesia strategies—serratus anterior plane and erector spinae plane blocks—improve peri-procedural and postoperative analgesia and can reduce opioid requirements in thoracic surgery and trauma pathways [33,34].
To reduce the risk of re-expansion pulmonary edema, the authors suggest limiting initial fluid evacuation to 1000–1500 mL and starting with a water seal in symptomatic patients, allowing for gradual re-expansion [35].
Suture and fixation techniques influence the risk of dislodgement, and adjunctive devices, such as intrapleural balloons, have been investigated to reduce fall-out, emphasizing the importance of securement in mobilizing patients early [36,37].
Chest tube insertion is a low bleeding risk procedure, and it is generally safe with an international normalized ratio (INR) <3.0 with platelets ≥20,000/µL. Generally, anticoagulants do not require interruption when these targets are met [38]. A meta-analysis (>5000 procedures) confirms low bleeding risk for thoracentesis and tube thoracostomy without routine correction of coagulopathy [39].

4. Devices Selection

4.1. Tube Size Selection: Matching Indication to Caliber

Evidence favors single-drain strategies after lobectomy for reduced pain and earlier mobilization without increased reintervention, and expert consensus considers 19–24 Fr a reasonable default pending further study of smaller drains (see Table 1 for an at-a-glance caliber-by-indication map) [16,40,41].
However, tube diameter should also be modulated according to the expected viscosity and coagulability of pleural output. In “dry” lobectomies, where the main concern is air evacuation, small-bore drains within the 19–24 Fr range or even smaller may be adequate. Conversely, when neoadjuvant chemo-immunotherapy or anti-angiogenic regimens and complex resections increase the risk of postoperative hemothorax, many surgeons deliberately retain larger-caliber drains (≥24 Fr) to reduce clot-related obstruction and delayed hemothorax, accepting a modest trade-off in terms of pain and invasiveness [42,43].
Volume and air-leak-oriented removal criteria allow safe early removal when daily output is modest and lungs are adequately expanded clinically and radiographically, especially within ERAS-aligned pathways [15,44,45].
Table 1. Suggested tube/catheter caliber by indication and context (adult). Evidence emphasizes smallest effective caliber outside coagulating hemothorax, with institutional protocols for trauma.
Table 1. Suggested tube/catheter caliber by indication and context (adult). Evidence emphasizes smallest effective caliber outside coagulating hemothorax, with institutional protocols for trauma.
IndicationDefault CaliberAlternatives/NotesKey Evidence
Post-lobectomy19–24 Fr single drainSmaller drains under investigation in trials; consider ≥24 Fr when a higher risk of bloody or highly viscous output is anticipated (e.g., neoadjuvant chemo-immunotherapy, complex resections); omission limited to selected minor resections.[15,16,40,41,42,43,46,47,48,49,50]
PSP/SSP≤14 Fr Seldinger catheterAmbulatory valve or portable digital in selected; avoid immediate high suction after chronic collapse[12,51,52,53,54,55,56,57,58,59,60,61,62,63,64]
Traumatic Htx/HPTX (stable)28–32 Fr (traditional)Protocolized small-bore (≤14–20 Fr) with imaging surveillance and early escalation[3,57,58,59,60,65,66,67]
Empyema/complicated PPE/TPESmall-bore feasible with image guidanceThick fibrinopurulent collections are prone to clog small drains; ensure regular flushing and early escalation to rTPA/DNase or VATS if needed. In organized empyema requiring decortication, prefer postoperative larger surgical tubes (≈24–28 Fr).[61,62,68,69,70]
MPEIPC (ambulatory) or chest tube + talcChoose by expansion potential, logistics, preference[47,63,71,72,73]
Chylothorax19–24 Fr (context dependent)Early multidisciplinary escalation if high-output[17,74]
Fr: French; Htx/HPTX: hemothorax/hemopneumothorax; PPE: parapneumonic effusion; TPE: tuberculous pleural effusion; rTPA/DNase: recombinant tissue plasminogen activator/deoxyribonuclease; MPE: malignant pleural effusion; IPC: indwelling pleural catheter.
Small-bore catheters (≤14 Fr) offer comparable success to larger tubes for air evacuation, with less pain and the feasibility of ambulatory management using one-way valves or portable digital units in selected patients with spontaneous pneumothorax [12,51,75].
While advanced trauma life support (ATLS) traditionally endorses 28–32 Fr tubes for hemothorax, contemporary randomized and comparative data—including a 2024 meta-analysis—show that protocolized small-bore strategies can achieve similar clinical outcomes in selected settings, provided explicit surveillance and escalation thresholds are in place (institutional protocol elements in Table 2) [65,66,76].
Overall, the “smallest effective caliber” principle must not override the physics of draining viscous or coagulating collections. According to Poiseuille’s law, even modest reductions in internal radius markedly impair flow, so small-bore catheters are intrinsically more vulnerable to clotting or occlusion when managing hemothorax or thick pus. Contemporary pleural infection and empyema statements therefore support small-bore drains plus intrapleural tPA/DNase for early, free-flowing disease, but emphasize prompt escalation to VATS or decortication when organized fibrinous material prevents effective drainage [17,42].

4.2. Drainage Hardware: Analogue and Digital Systems

Analogue three-chamber systems integrate collection, water-seal, and suction control into a single disposable unit, using bubbling as a qualitative surrogate for air leaks and negative intrapleural pressure [4,9].
Even when wall suction is disconnected, the water-seal chamber continues to transmit the patient’s spontaneous negative pleural pressure, thereby maintaining a slightly subatmospheric intrapleural environment and preventing retrograde flow rather than creating a true “zero-pressure” state [8,31].
Digital systems introduced regulated suction with continuous airflow and pressure telemetry, improving standardization of mobility and informing removal decisions through quantitative thresholds rather than subjective bubbling alone (parameters and typical ranges summarized in Table 3) [20,21].
Multiple randomized and prospective trials demonstrate at least non-inferiority of digital devices in reducing air-leak duration and hospital length of stay, with several studies reporting workflow and patient-experience advantages that support broader ERAS implementation [20,80,81]. Device generations differ in flow-measurement algorithms, display resolution, and alarm logic, which may contribute to heterogeneous trial results and underscore the value of center-specific familiarization and protocolization [21].

4.3. Suction Versus Water-Seal: Physiology Meets Device Behavior

Meta-analyses and randomized trials do not show a consistent benefit of routine continuous suction after lung resection, supporting an early transition to water-seal in appropriate patients to reduce air-leak duration and facilitate mobilization [24,82].
On digital platforms, “seal” corresponds to a low-regulated negative pressure rather than zero suction. Trials comparing low-regulated suction versus seal reveal mixed results, without a universally superior target, arguing for titration to leak size, expansion, and space management [22,23,83].
Massive air leaks, incomplete expansion, or post-resection space may justify modest regulated suction with planned step-downs to low-pressure or seal modes as re-opposition progresses, balancing evacuation efficiency with patient comfort and mobility [21,22].

5. Clinical Assessment and Troubleshooting

5.1. Removal Criteria: Volume Thresholds and Airflow-Guided Decisions

Randomized trials and guideline syntheses support the removal of approximately 300–500 mL daily in the absence of blood or chyle, acknowledging that clinical stability and imaging confirmation remain crucial safeguards (see Table 4 for practical removal thresholds) [15,44,45].
Digital devices enable decisions based on sustained low airflow—commonly 20–40 mL/min—where very low residual flow may reflect physiologic pleural space effects rather than clinically significant bronchopleural fistulae, facilitating earlier, safe removal in selected cohorts [21,79,85].
Emerging evidence suggests that air-leak criteria alone can permit earlier removal than fluid-based thresholds without increasing adverse events, provided that post-removal monitoring and explicit rescue pathways are in place [51,86].
Before removing tubes for pneumothorax, a brief water-seal observation is usually sufficient, and routine clamping trials are not required due to the risk of tension pneumothorax [31].
Remove the drainage at end-expiration during Valsalva with an immediate occlusive dressing to minimize air ingress. A routine post-removal chest radiography is often unnecessary when observation is available and the patient is stable [87].

5.2. Postoperative Air-Leak Management and Omission Strategies

Persistent air leak remains a principal driver of morbidity and length of stay after lung resection, motivating preventive surgical strategies (e.g., fissure-last dissection, buttressing) and selective postoperative adjuncts such as autologous blood patch or endobronchial valves [88,89].
Digital telemetry supports standardized mobilization, suction titration, and objective timing of removal, potentially reducing variability and aligning teams around shared thresholds [21,81].
Tube omission after minor resections appears feasible within tightly defined protocols and careful selection, whereas omission after major resections remains investigational and should be restricted to trials or structured institutional pathways [46,90].

6. Contraindications: When to Prefer Alternatives

Relative contraindications include markedly loculated effusions, coagulopathy/bleeding diathesis, and overlying soft-tissue infection. The proper management of these situations requires a case-by-case risk–benefit assessment [35]. Clinical scenarios in which alternatives often supersede chest tubes include heart-failure effusions (diuresis), hepatic hydrothorax (TIPS/transplant), pneumothorax ex vacuo (conservative), trapped lung with MPE (IPC palliation), endobronchial obstruction (airway therapy), and mediastinal emphysema (oxygen/ventilatory adjustments) [91,92,93,94,95].

7. Special Pleural Conditions

Indwelling pleural catheters (IPC) provide ambulatory palliation with relief from dyspnea in patients with malignant pleural effusion, comparable to talc pleurodesis at fixed time points, fewer inpatient days, and autonomy in patients with non-expandable lungs or limited performance status [47,71].
IPCs reduce repeat interventions in selected comorbid populations when coupled with infection vigilance and community support, broadening the role of ambulatory non-malignant pleural care [72,96].
Efficacy hinges on drainage rather than caliber alone, with small-bore catheters performing well when paired with image guidance and escalation to intrapleural recombinant tissue plasminogen activator/deoxyribonuclease (rTPA/DNase) or surgery for loculated or non-resolving infectious collections [68,69].
In tuberculous pleural effusion, therapeutic thoracentesis or small-bore catheter drainage is usually sufficient for free-flowing effusions, whereas multiloculated or organized collections may require more aggressive strategies. In this setting, ultrasound-guided pigtail or large-bore drains combined with intrapleural fibrinolytics, and especially medical thoracoscopy with adhesiolysis and debridement, have shown high success rates, shorter drainage duration and hospital stay, and reduced need for further surgery, with low procedure-related morbidity [70].
Management of chylothorax integrates drainage, nutritional modification, consideration of somatostatin analogues, and early escalation to thoracic duct ligation or interventional radiology in high-output refractory cases, reinforced by multidisciplinary pathways (Table 1) [17,74].

8. Complications and Mitigation

Complications include malposition, organ or vascular injury, infection, occlusion, dislodgement, persistent leak, and re-expansion pulmonary edema, with incidence varying by setting and operator experience, highlighting the importance of ultrasound, checklists, and secure fixation (common pitfalls and prevention strategies are presented in Table 5) [97,98].
Reported complication rates vary (~1–40%); meta-analytic estimates suggest a rate of ~19% overall, with serious events being uncommon [28,103].
Most positional complications (kinking, obstruction, and fissural entrapment) are managed by repositioning or exchanging the drainage. Pure insertional injuries are rare in experienced centers [104].
Avoiding the abrupt application of high negative pressure in young patients with long-standing collapse mitigates the risk of re-expansion pulmonary edema, and stepwise evacuation strategies are prudent in this scenario [96,105].
In suspected empyema, empiric antibiotic therapy should cover anaerobes and common pleuropulmonary pathogens [99]. Antibiotic prophylaxis for tube thoracostomy in trauma shows context-dependent benefit in meta-analysis and should be tailored to local epidemiology and stewardship principles [21,106].

9. Tactical Bedside Algorithms

After lobectomy, use a single 19–24 Fr drain by default, favor early water-seal (analogue) or low-pressure “seal” modes (digital), encourage early mobilization, and remove at ≤450 mL/day without blood or chyle or when digital airflow is consistently ≤20–40 mL/min with satisfactory clinical and radiographic expansion [15,16,44].
In primary and secondary pneumothorax, prefer small-bore Seldinger catheters (≤14 Fr) with an ambulatory valve or portable digital pathways, where appropriate. Reserving larger drains for viscous effusions, mixed air-fluid collections, or institutional mandates. Avoid immediate high suction after chronic collapse [12,51,105].
Trauma patients maintain readiness for 28–32 Fr tubes, consistent with ATLS, while protocolized small-bore strategies were supported by team consensus and contemporary evidence. This ensures imaging surveillance and clear escalation to fibrinolytics, video-assisted thoracic surgery (VATS), or thoracotomy for retained collections [66,67,76].
For malignant effusion, choose IPC for ambulatory palliation or talc pleurodesis when the lung fully expands and hospitalization is acceptable, aligning with patient goals, resource availability, and expected survival [47,71].
In cases of pleural infection, we use image guidance to target loculations, emphasize adequate drainage over caliber, and escalate to rTPA/DNase or surgery when non-resolving despite appropriate catheterization and antibiotics (key evidence-based overview in Table 6) [68,69].

10. Future Directions

Priorities include harmonizing definitions and targets for digital “seal” and low-suction settings, validating device-agnostic airflow thresholds for removal, and integrating telemetry with clinical predictors to produce individualized, learning health-system pathways [21,22]. Prospective, multicenter protocols that bridge emergency medicine, pleural medicine, and thoracic surgery are needed to expand small-bore strategies in trauma safely and to optimize ambulatory pathways for pneumothorax and malignant pleural effusion while safeguarding against undertreatment of complex collections [18,65].

11. Discussion

Modern chest-drain practice rests on three pillars—right tube, right system, and proper criteria—implemented through multidisciplinary protocols that emphasize the smallest effective caliber, selective regulated suction or early water-seal, and standardized removal thresholds grounded in trials and consensus [15,16,24]. Digital systems help objectify low-flow states and support earlier, safer removal. In contrast, analog units benefit from prompt conversion to water-seal in suitable patients, with escalation reserved for non-expansion or large leaks [21,82]. Institutional consistency, ultrasound-guided technique, and secure fixation reduce complications and enable mobility, while ambulatory pleural pathways extend effective care beyond the ward for pneumothorax and malignant effusions [12,29,36].

12. Conclusions

Finally, it should be acknowledged that much of the evidence underpinning chest tube size, dwell time, and stepwise escalation in pleural infection is derived from heterogeneous, often low-quality studies, and that many high-volume centers favor early surgical decortication in more complicated clinical scenarios rather than prolonged small-bore/lytic pathways [110]. Ultimately, the rational, evidence-based use of pleural drains must be contextualized at the intersection of multiple indications and patient trajectories, integrated with accumulated clinical experience and, whenever feasible, the direct supervision of thoracic surgeons or interventional pulmonologists, as advocated by contemporary international guideline recommendations [111].

Author Contributions

Conceptualization, P.A.F., C.B.S., A.G.F. and A.M.; methodology, P.A.F., C.B.S., A.G.F. and A.M.; validation P.A.F., C.B.S., E.P., M.S., G.C., A.F., A.G.F. and A.M.; resources, P.A.F. and C.B.S.; writing—original draft preparation, P.A.F., C.B.S., E.P., A.F., A.G.F. and A.M.; writing—review and editing, P.A.F., C.B.S., E.P., M.S., G.C., A.F., A.G.F. and A.M.; supervision, P.A.F. and C.B.S. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Ethical review and approval were waived for this study due to its design as a narrative review of previously published literature involving no new data collection from human participants or animals, no interventions, and no analysis of identifiable personal information, and therefore lying outside the remit of institutional ethics committee oversight.

Informed Consent Statement

Not applicable.

Data Availability Statement

No new data were created for this study.

Conflicts of Interest

The authors declare no conflicts of interest.

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Table 2. Small-bore adoption in trauma: protocol elements. Safeguards for patient selection and escalation.
Table 2. Small-bore adoption in trauma: protocol elements. Safeguards for patient selection and escalation.
ElementSpecification
EligibilityHemodynamically stable; no massive Htx; CT/POCUS available
Catheter≤14–20 Fr Seldinger catheter placed with image guidance when feasible
MonitoringOutput charting; repeat CXR/POCUS at 6–24 h
EscalationFibrinolytics (tPA ± DNase) or VATS for retained clot; convert to large-bore for failure
GovernanceMultidisciplinary protocol; QA review of outcomes
Htx: hemothorax; CT/POCUS: computed tomography/point-of-care ultrasound; Fr: French; CXR: chest x-ray; tPA ± DNase: recombinant tissue plasminogen activator ± deoxyribonuclease; VATS: video-assisted thoracic surgery; QA: quality assurance.
Table 3. Digital drainage: typical settings and interpretation. Device generations differ; interpret locally validated thresholds.
Table 3. Digital drainage: typical settings and interpretation. Device generations differ; interpret locally validated thresholds.
ParameterTypical RangePractical Interpretation
“Seal” setting≈ −2 to −8 cm H2OLow regulated negative pressure, not zero suction [64,77,78]
Moderate suction−10 to −20 cm H2OUse for larger leaks or suboptimal expansion [64,77,78]
Low airflow threshold≤20–40 mL/minCommon removal criterion with full expansion [79]
High airflow>100–200 mL/minMaintain suction; evaluate for PAL/BPF [21]
mL/min: milliliter/minute; PAL/BPF: prolonged air leak/broncho-pleural fistula.
Table 4. Removal criteria by pathway. Converging evidence supports fluid or airflow thresholds plus clinical expansion.
Table 4. Removal criteria by pathway. Converging evidence supports fluid or airflow thresholds plus clinical expansion.
PathwayCriteriaNotes
Volume-based≤300–500 mL/24 h; non-bloody/non-chylousRandomized trials and ERAS guidance support upper bound approximately 450–500 mL/day [15,44,45,75,84]
Air-leak analogueNo bubbling with cough/respirationEnsure imaging/clinical expansion [85]
Digital airflow≤20–40 mL/min sustained 6–12 hConsider skipping clamp trial when telemetry stable [21,79]
mL: milliliter; ERAS: enhanced recovery after surgery.
Table 5. Common complications and mitigation. Technique, ultrasound, and securement reduce risk.
Table 5. Common complications and mitigation. Technique, ultrasound, and securement reduce risk.
ComplicationContributorsMitigation
Malposition/extrathoracic placementAnatomical variation; emergent settingUltrasound guidance; safety-triangle entry; superior rib border; confirm position [29,30]
Organ/vascular injuryTrocar use; low intercostal spacesAvoid trocar; above 5th ICS when feasible; image guidance [27,32]
InfectionProlonged dwell; trauma contextAsepsis; stewardship; consider prophylaxis per local data (trauma) [99]
Occlusion/clotHigh viscosity; small caliber in HtxEarly reassessment; escalation or VATS if retained clot [59,60,67]
DislodgementPoor fixation; early mobilizationRobust suture/securement; nursing protocols [11,36]
Re-expansion pulmonary edemaRapid suction after chronic collapseGradual re-expansion; initially low pressure [100,101,102]
ICS: intercostal space; VATS: video-assisted thoracic surgery.
Table 6. Landmark randomized trials/meta-analyses informing chest-drain management. Selected exemplars across domains.
Table 6. Landmark randomized trials/meta-analyses informing chest-drain management. Selected exemplars across domains.
DomainTrial (Year)DesignKey Finding
Post-resection tubesGómez-Caro 2006; Okur 2009RCTsSingle drain non-inferior/superior for pain and mobilization [40,41]
Removal thresholdsBjerregaard 2014; Gioutsos 2024; Xie 2015RCTsSafe removal at ≤300–500 mL/day or air-leak-guided [44,84,86]
Digital vs. analogueComacchio 2023; Lijkendijk 2015; Plourde 2018;RCTsNon-inferior; workflow/patient benefits in several trials [20,102,107]
Suction vs. sealMarshall 2002; Cerfolio 2001; Brunelli 2004RCTsNo routine benefit of continuous suction; early seal favored [82,108,109]
Trauma caliberBauman 2021; Lyons 2024RCT + Meta-analysisSmall-bore feasible in selected settings with protocols [65,66]
RCTs: randomized control trials; mL: milliliter.
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Ferrari, P.A.; Salis, C.B.; Pusceddu, E.; Santoru, M.; Canu, G.; Ferrari, A.; Fois, A.G.; Maccio, A. Comprehensive Overview of Current Pleural Drainage Practice: A Tactical Guide for Surgeons and Clinicians. Surgeries 2025, 6, 108. https://doi.org/10.3390/surgeries6040108

AMA Style

Ferrari PA, Salis CB, Pusceddu E, Santoru M, Canu G, Ferrari A, Fois AG, Maccio A. Comprehensive Overview of Current Pleural Drainage Practice: A Tactical Guide for Surgeons and Clinicians. Surgeries. 2025; 6(4):108. https://doi.org/10.3390/surgeries6040108

Chicago/Turabian Style

Ferrari, Paolo Albino, Cosimo Bruno Salis, Elisabetta Pusceddu, Massimiliano Santoru, Gianluca Canu, Antonio Ferrari, Alessandro Giuseppe Fois, and Antonio Maccio. 2025. "Comprehensive Overview of Current Pleural Drainage Practice: A Tactical Guide for Surgeons and Clinicians" Surgeries 6, no. 4: 108. https://doi.org/10.3390/surgeries6040108

APA Style

Ferrari, P. A., Salis, C. B., Pusceddu, E., Santoru, M., Canu, G., Ferrari, A., Fois, A. G., & Maccio, A. (2025). Comprehensive Overview of Current Pleural Drainage Practice: A Tactical Guide for Surgeons and Clinicians. Surgeries, 6(4), 108. https://doi.org/10.3390/surgeries6040108

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