DDX of chest tube malfunction

Approach to the DDX of chest tube malfunction:

  • If a chest tube placed to treat a pneumothorax or pleural effusion does not reduce the size of the pneumothorax or pleural effusion, investigate it closely for evidence of malposition in the subcutaneous tissues or lung
  • If a pneumothorax or pleural effusion that had been successfully treated by a chest tube reaccumulates in size, investigate it carefully for evidence of migration out of the pleural space
  • A chest tube placed to drain pneumothorax, pleural effusion, or pleural empyema can cause a bronchopleural fistula which may first manifest as a hydropneumothorax
  • In congenital diaphragmatic hernia it is normal to have pleural air on the immediate post-op CXR because the hypoplastic lung bud cannot immediately reexpand to fill pleural space and the pleural space will fill with fluid over time until the lung bud grows to its normal size. Air or fluid in the pleural space after congenital diaphragmatic hernia repair is never an indication for chest tube placement