• Pleural space infections with positive Gram stain or culture OR parapneumonic effusions without pleural fluid sampling
  • 3 stages
    • 1. Exudative
      • Free-flowing pleural effusion amenable to chest tube drainage; may only last <48hr
    • 2. Fibrinopurulent
      • Loculations develop making resolution w/ single chest tube drainage unlikely
    • 3. Organizational
      • Takes several weeks to develop; "pleural peel" restricts lung expansion


Clinical Features

  • Usually preceded by PNA
    • Suspect if symptoms of PNA do not resolve

Differential Diagnosis


  • Aspiration of purulent material on thoracentesis and at least 1 of the following:
    1. Positive Gram stain or culture
    2. Pleural fluid glucose <40
    3. pH <7.1
    4. LDH >1000


Adult Chest Tube Sizes

Chest Tube Size Type of Patient Underlying Causes
Small (8-14 Fr)
  • Alveolar-pleural fistulae (small air leak)
  • Iatrogenic air
Medium (20-28 Fr)
  • Bronchial-pleural fistulae (large air leak)
  • Malignant fluid
Large (36-40 Fr)
  • Traumatic pneumothorax
    • 2012 study using 28-32 Fr tube just as good as 36-40 Fr tube. [1] This is reflected in the ATLS 2019 Guidelines: "ATLS ® -10 now recommends placement of a smaller 28F to 32F chest tube for any acute hemothorax that is visible on chest radiograph." [2]
  • Empyema
  • Bleeding (Hemothorax/hemopneumothorax)
  • Thick pus

See Also


  • Tintinalli
  • Inaba Et. al J Trauma Acute Care Surg. 2012 Feb;72(2):422-7.
  • Advanced Trauma Life Support® Update 2019: Management and Applications for Adults and Special Populations.