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

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Overall a good overview chest tube management. Some small areas that I would consider revising or adding to:

Chest tube size. These are good generic goals but there may be room in table 1 to mention some of the caveats, eg the consistency of fluid coming out. A lobectomy might be very dry and one is only worried about air in which case a small bore is reasonable, but in the age of immuno, many lobectomies are quite bloody and the risk of tube clotting and subsequent hemothorax is large with a small bore. Similarly with empyema, small bore +/- lytics may be an option for liquid pus but lytics will not disolve fibrinous chunks, just break up loculations and so there is a high risk of clogging. Also with empyema, would just clarify that 14fr is reasonable pre surgery, but decortication is still the gold standard so I would mention chest tube side after surgery, normally 24-28.

In terms of digital suction devices, you mention that these have a low setting to mimic waterseal. You might want to mention that even when a normal atrium is off suction, there is still negative pressure maintained by the waterseal and that is why the digital devices need to minimic this setting. 

Overall however I think that this is a great artical and helpful to many who are not using them routine. At the end, it might be worth discussing that many of the studies that look at chest tube site are not high quality data and so there is quite a lot of variability in size of tube, how long tubes are left in, and the order of intervention for things like empyema ie many places are aggressive about upfront decortication instead of waiting for a small bore to fail, and then lytics, and then surgery. 

Author Response

Overall a good overview chest tube management. Some small areas that I would consider revising or adding to:

C1: Chest tube size. These are good generic goals but there may be room in table 1 to mention some of the caveats, eg the consistency of fluid coming out. A lobectomy might be very dry and one is only worried about air in which case a small bore is reasonable, but in the age of immuno, many lobectomies are quite bloody and the risk of tube clotting and subsequent hemothorax is large with a small bore. Similarly with empyema, small bore +/- lytics may be an option for liquid pus but lytics will not disolve fibrinous chunks, just break up loculations and so there is a high risk of clogging. Also with empyema, would just clarify that 14fr is reasonable pre surgery, but decortication is still the gold standard so I would mention chest tube side after surgery, normally 24-28.

R1: Thank you very much for your thoughtful comments and practical suggestions. In response, we clarified in the text and in Table 1 that chest tube size should be tailored not only to indication, but also to the expected viscosity and coagulability of pleural output. We now explicitly discuss small-bore drains for “dry” lobectomies versus larger tubes when bloody output is anticipated, the risk of clogging in empyema with thick pus despite lytics, and the usual use of 24–28 Fr drains after surgical decortication.

C2: In terms of digital suction devices, you mention that these have a low setting to mimic waterseal. You might want to mention that even when a normal atrium is off suction, there is still negative pressure maintained by the waterseal and that is why the digital devices need to minimic this setting.

R2: Thank you very much for this insightful comment. We have revised the section on conventional water-seal systems to clarify that, even when wall suction is turned off, the water-seal chamber continues to transmit the patient’s spontaneous negative pleural pressure. Thus, an off-suction analogue atrium still maintains a slightly subatmospheric intrapleural environment and prevents retrograde flow, rather than creating a true “zero-pressure” state. This better explains why digital systems are designed to mimic this physiological condition. 

C3: Overall however I think that this is a great artical and helpful to many who are not using them routine. At the end, it might be worth discussing that many of the studies that look at chest tube site are not high quality data and so there is quite a lot of variability in size of tube, how long tubes are left in, and the order of intervention for things like empyema ie many places are aggressive about upfront decortication instead of waiting for a small bore to fail, and then lytics, and then surgery.

R3: Thank you very much for this helpful comment. In line with your suggestion, we have added a closing sentence to the Conclusion explicitly acknowledging that much of the evidence on chest tube size, duration, and escalation strategies (including management of empyema) is heterogeneous and often low-quality, and that practice patterns vary substantially, with some centers favoring early surgical decortication rather than prolonged small-bore and lytic pathways. 

Reviewer 2 Report

Comments and Suggestions for Authors

Dear colleagues! This article is devoted to various options for performing thoracocentesis and drainage of the pleural cavity after various pathological conditions - hydrothorax, pneumothorax, chylothorax, after lung resection and others. Despite the fact that this manipulation has been known for a long time, there are no generally accepted methods for its implementation. This article provides a detailed systematic review of the data from 105 literature sources. The authors conduct a detailed analysis of the drainage installation technique, depending on the pathology and drainage size. The complications and effectiveness of performing this manipulation were also separately evaluated. This article will be useful not only for thoracic surgeons, but also for general surgeons and pulmonologists. The article is executed at a high level, it can be accepted for publication after minor editorial changes. The authors have not evaluated the effectiveness of performing thoracocentesis and drainage of the pleural cavity in tuberculous pleurisy, although this is one of the common reasons for performing thoracocentesis. If the authors had added literature sources that provided information on how to perform pleural drainage in tuberculosis, this would have further enhanced the article.

Author Response

Dear colleagues! This article is devoted to various options for performing thoracocentesis and drainage of the pleural cavity after various pathological conditions - hydrothorax, pneumothorax, chylothorax, after lung resection and others. Despite the fact that this manipulation has been known for a long time, there are no generally accepted methods for its implementation. This article provides a detailed systematic review of the data from 105 literature sources. The authors conduct a detailed analysis of the drainage installation technique, depending on the pathology and drainage size. The complications and effectiveness of performing this manipulation were also separately evaluated. This article will be useful not only for thoracic surgeons, but also for general surgeons and pulmonologists. The article is executed at a high level, it can be accepted for publication after minor editorial changes. The authors have not evaluated the effectiveness of performing thoracocentesis and drainage of the pleural cavity in tuberculous pleurisy, although this is one of the common reasons for performing thoracocentesis. If the authors had added literature sources that provided information on how to perform pleural drainage in tuberculosis, this would have further enhanced the article.

R: Thank you very much for your thoughtful comments and valuable suggestion. As recommended, we have added a dedicated and more exhaustive paragraph on the management of tuberculous pleural effusion within the “Special conditions” section, including the treatment of complicated TB-related effusions. We have also incorporated an appropriate reference and updated Table 1 accordingly.

Reviewer 3 Report

Comments and Suggestions for Authors

I congratulate the authors for this detailed study of pleural drainage.

After analyzing this paper, I have the following observations:

• I request the authors to explain all abbreviations used in the text
• in lines 142 and 255 the authors are referring to tension pneumothorax?
• in the sentence from lines 227-229 do the authors also include pneumonectomy when referring to lung resections?

Author Response

I congratulate the authors for this detailed study of pleural drainage.

After analyzing this paper, I have the following observations:

C1: I request the authors to explain all abbreviations used in the text

R1: Thank you for your valuable advice. We reviewed all the abbreviations implementing the missing ones.

C2: in lines 142 and 255 the authors are referring to tension pneumothorax?

R2: Thank you very much for your helpful advice. We modified the term “physiology” (unvolountary edited by the Language checker) with the correct one “pneumothorax”

C3: in the sentence from lines 227-229 do the authors also include pneumonectomy when referring to lung resections?

R3: Thank you very much for your insightful comment. In order to avoid misunderstaing we clarified which  kind of pulmonary resection benefit from continuous suction on chest drain.

Reviewer 4 Report

Comments and Suggestions for Authors

Chest tube drainage is a key procedure for patients after thoracic surgeries, with large amount of hydrothorax, spontaneous pneumothorax, and lunge injuries. However, there are still some issues that are not made in consensus among different centers and physicians. In addition, the criteria for drainage tube management also varies among different clinical situations, such as lung cancer surgeries, pneumonia, chest trauma ect. Taking the criteria for chest drainage tube remove after lobectomy for lung cancer for example, big controversaries exist in terms of when the tube can be removed and what about the tuber caliber is suitable. This study is a review that 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. The main content of this study is clinical valuable in harmonizing drainage tube choices, system settings, and standardized removal criteria for doctors. The collection of data from previously published studies are sound and the summary of the publications are helpful for clinical decision-making in terms of drainage tube management. I therefore recommend a reception for publication for the reasons below.

1. The topic of this study arises from clinical question that need to be elucidated: How to manage the chest drainage tube for varieties of disease situations.
2. This study is a comprehensive analysis on drainage tube choices, system settings, and standardized removal criteria for doctors, but not only focus on one clinical scenario.
3. The study cited all of the important references based on which to take the message for the readers to understand the current evidence of chest tube management. The paper not only contribute to literature but more importantly, play a role in guidance of this field.
4. The paper is well organized with an object conclusion. The publication of this paper will contribute to standardize clinical practice of chest tube management in varieties of diseases and medical scenarios.

 

Author Response

Chest tube drainage is a key procedure for patients after thoracic surgeries, with large amount of hydrothorax, spontaneous pneumothorax, and lunge injuries. However, there are still some issues that are not made in consensus among different centers and physicians. In addition, the criteria for drainage tube management also varies among different clinical situations, such as lung cancer surgeries, pneumonia, chest trauma ect. Taking the criteria for chest drainage tube remove after lobectomy for lung cancer for example, big controversaries exist in terms of when the tube can be removed and what about the tuber caliber is suitable. This study is a review that 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. The main content of this study is clinical valuable in harmonizing drainage tube choices, system settings, and standardized removal criteria for doctors. The collection of data from previously published studies are sound and the summary of the publications are helpful for clinical decision-making in terms of drainage tube management. I therefore recommend a reception for publication for the reasons below.

1. The topic of this study arises from clinical question that need to be elucidated: How to manage the chest drainage tube for varieties of disease situations.
2. This study is a comprehensive analysis on drainage tube choices, system settings, and standardized removal criteria for doctors, but not only focus on one clinical scenario.
3. The study cited all of the important references based on which to take the message for the readers to understand the current evidence of chest tube management. The paper not only contribute to literature but more importantly, play a role in guidance of this field.
4. The paper is well organized with an object conclusion. The publication of this paper will contribute to standardize clinical practice of chest tube management in varieties of diseases and medical scenarios.

R: Thank you very much for your thoughtful and generous evaluation. We are grateful for your positive assessment and recommendation for publication of our manuscript.

Reviewer 5 Report

Comments and Suggestions for Authors

• Keywords should be between 3 and 5.
• It should include visuals or a graphic abstract to better illustrate the applications.

 ABSTRACT

• PRISMA is a systematic method, so the positive and negative aspects of the treatments applied in the study should be included.
• The aim of the study must be stated in this section.

 INTRODUCTİON

• Paragraphs in chronological order, the text should discuss the situations created by the treatments over the years.
• The study is insufficient in terms of patient data (evidence) and references.
• Only two references are included, apart from the 7th and 8th paragraphs. The number of references in the paragraphs should be increased.

 MATERİAL AND METOD

• The author indicates that the study used two methods to analyse the data in the materials and methods section, whereas the author could have included prospective Cohort studies.
• Having systematic content and using qualitative data raises the question of whether they are compatible with the PRISMA modeling.
• No ethics committee document is included.
• The start date/range of the search should be written instead of the article's search date (2025).
• References are given only in the initial part; the references should be multiplied/increased.

 DISCUSSION

• A discussion section should be included.

 CONCLUSİON

• Well writing

 REFERENCE

• Current articles should be included.

Author Response

C1: Keywords should be between 3 and 5.

R1: Thank you very much for your advice. We reduced keywords numbers to 5.

C2: It should include visuals or a graphic abstract to better illustrate the applications.

R2: Thank you very much for your suggestion. We designed a graphical abstract according to journal criteria.

 ABSTRACT

C3: PRISMA is a systematic method, so the positive and negative aspects of the treatments applied in the study should be included.

R3: Thank you very much for this helpful comment. In response, we revised the Abstract to make explicit that our PRISMA-modeled narrative review qualitatively summarizes both advantages and drawbacks of the main drainage strategies, including small- versus large-bore tubes, analog versus digital systems, and suction versus water-seal approaches, highlighting benefits, complications, and practical trade-offs for clinical decision-making.

C4: The aim of the study must be stated in this section.

R4: Thank you for this helpful comment. We have revised the last sentence of the Introduction within the Abstract to explicitly state the aim of the review, clarifying that our purpose is to synthesize available evidence and translate it into pragmatic guidance.

 INTRODUCTİON

C5: Paragraphs in chronological order, the text should discuss the situations created by the treatments over the years.

R5: Thank you very much for your insightful comment. We revised the Introduction, reassembling paragraphs according a more linear historical flow of narration.

C6: The study is insufficient in terms of patient data (evidence) and references.

R6: Thank you very much for this comment. We fully agree on the importance of grounding the review in robust clinical evidence. In keeping with the aims and structure of our article, we intentionally limited the Introduction to a concise historical overview of chest drainage. Nevertheless, this section already cites more than twenty key references—approximately one fifth of all citations in the manuscript—while the subsequent sections provide a detailed, evidence-based appraisal of patient data and contemporary practice.

C7: Only two references are included, apart from the 7th and 8th paragraphs. The number of references in the paragraphs should be increased.

R7: Thank you for your comment. All the coherent references have been included along the introduction section.

 MATERİAL AND METOD

C8: The author indicates that the study used two methods to analyse the data in the materials and methods section, whereas the author could have included prospective Cohort studies.

R8: Thank you very much for this comment. As clarified in the Materials and Methods section, our narrative review did not rely on only two study designs, but systematically prioritized randomized controlled trials, prospective cohort studies, meta-analyses, and professional-society guidelines, supplemented by high-quality observational cohorts when randomized/prospective data were limited. To avoid ambiguity, we report the relevant statements: “…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,…” and “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.”

 

C9: Having systematic content and using qualitative data raises the question of whether they are compatible with the PRISMA modeling.

R9: Thank you for this thoughtful comment. We fully agree that PRISMA was developed for systematic reviews. In our manuscript, however, PRISMA is explicitly used only as a framework for transparency in a targeted narrative review, not as a full PRISMA-compliant systematic review. As stated and now further clarified in the Materials and Methods section, we adopted PRISMA principles (question framing, source identification, and selection reporting) to enhance reproducibility, while intentionally performing a qualitative synthesis without protocol registration or quantitative pooling.

C10: No ethics committee document is included.

R10: Thank you for you valid comment: 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.

C11: The start date/range of the search should be written instead of the article's search date (2025).

R11: Thank you for your insightful advice. In the materials and methods, we stated that we cited index syntheses and relevant studies published up to 2025.

C12: References are given only in the initial part; the references should be multiplied/increased.

R12: Thank you very much for your valuable comment. We apologize for this inconvenien and we added avery important reference that describe the backward “snowballing” citation method.

 DISCUSSION

C13: A discussion section should be included.

R13: Thank you very much for your valuable suggestion. We added a brief Discussion section to our manuscript.

 CONCLUSİON

C14: Well writing

R14: Thank you very much for your comment.

 REFERENCE

C15: Current articles should be included.

R15: Thank you very much for your suggestion. We added references published in 2024 and 2025.

Round 2

Reviewer 5 Report

Comments and Suggestions for Authors

The revisions were done.