Zad Talk
Small-Bore vs. Large-Bore Chest Tubes: Does Size Really Matter for Hemothorax and Pleural Effusions?

When it comes to placing a chest tube—also known as a thoracostomy tube—to manage hemothorax or pleural effusion, traditional teaching has often defaulted to the phrase “bigger is better.” For years, large-bore tubes (often around 36-40 French) were considered the gold standard, especially in trauma settings, because the logic went something like this: A bigger tube removes fluid or blood more quickly and effectively, prevents clots from forming inside, and reduces the chance of complications down the road. But medicine is always evolving, and several recent studies have challenged this long-standing belief. Increasingly, evidence suggests that small-bore chest tubes (often in the range of 14 French or even smaller) can be just as effective as their bulkier counterparts.
So, is it time to reconsider the “bigger is better” mantra? Let’s take a look at the science and see what the evidence-based medicine of today tells us about choosing a tube size for hemothorax and pleural effusions, both in trauma and malignant disease settings.
The Rationale Behind Smaller Tubes
Before diving into the research, let’s talk about why smaller chest tubes are even on the table. Large-bore chest tubes are not exactly fun. They can be painful to insert and can cause discomfort for the patient while they remain in place. Smaller tubes, being narrower, can be placed using less invasive techniques, often under local anesthesia and with imaging guidance. They’re more comfortable for patients, potentially reduce pain, and can be easier to manage. And if they’re just as effective at draining fluid or blood, then why wouldn’t we choose the more patient-friendly option?
This is precisely what researchers and clinicians have been asking themselves over the last decade. The following studies shed some light on this debate.
Evidence in Traumatic Hemothorax
Inaba et al. (2012)1
In trauma, the longstanding tradition was big tubes all the way. The fear: if you don’t clear blood quickly, you risk clots, retained hemothorax, infection, and possibly the need for additional interventions. But a prospective study by Inaba and colleagues challenged this assumption. Published in The Journal of Trauma and Acute Care Surgery (2012), this study examined patients with traumatic hemothorax who were managed with either small-bore (28-32 Fr) or large-bore (36-40 Fr) chest tubes. The results might surprise you.
Inaba’s team found no significant difference in key clinical outcomes between the two groups. Retained hemothorax rates? About the same. Need for additional tube placement? Similar. Major invasive procedures down the line? No major difference. In short, the study concluded that when it comes to draining blood from a traumatic hemothorax, small-bore tubes appeared to be just as effective as large-bore tubes.
Lyons et al. (2024)2
If one study nudges the door open, a systematic review and meta-analysis can swing it wide open. A recent analysis by Lyons and colleagues (2024) pooled data from multiple studies looking at small-bore (≤14 Fr) vs. large-bore (≥20 Fr) thoracostomy for traumatic hemothorax. Their findings support Inaba’s: there were no significant differences in failure rates, mortality, or complication rates between the two approaches. The message is consistent: small-bore tubes can get the job done just as well in trauma scenarios, and they may carry the added benefits of being less invasive and more comfortable.
Evidence in Pleural Effusion
We’ve seen what happens in trauma, but what about non-traumatic pleural effusions, such as those caused by malignancy? Here, there’s often more time for planning and less of a chaotic emergency environment. In these settings, patient comfort and quality of life considerations are paramount. If small-bore tubes can provide equal efficacy, that’s a big deal for patients living with conditions like metastatic cancer.
Thethi et al. (2018)3
A meta-analysis by Thethi and colleagues in Journal of Thoracic Disease (2018) looked specifically at the efficacy of pleurodesis in malignant pleural effusions. Pleurodesis is a procedure that seals the pleural space to prevent fluid from re-accumulating. If small-bore tubes couldn’t drain the fluid effectively in the first place or caused more complications, pleurodesis would be less successful. The results? No significant difference in the success of pleurodesis or complication rates between small and large chest tubes. This means that patient comfort does not have to be sacrificed for effectiveness.
Parulekar et al. (2001)4
Even going back over two decades, researchers like Parulekar and colleagues were noticing that small-bore catheters worked just as well as large-bore chest tubes for draining and sclerotherapy of malignant pleural effusions. They found no significant differences in outcomes. If the data was pointing in that direction then, and more recent studies continue to confirm it, we may safely conclude that size often doesn’t dictate success.
Why Are Smaller Tubes Just as Effective?
It might seem counterintuitive that a smaller-diameter tube could handle thick fluids or clots as well as a larger one. After all, bigger tubes have more lumen space. But as it turns out, good technique and proper management may matter more than raw diameter.
For hemothorax, the traditional fear was that smaller tubes might clot more easily. While intuitively this might make sense, the actual data doesn’t strongly support that concern. Instead, as long as the tube is positioned correctly and managed appropriately—with potential adjuncts such as fibrinolytics when needed—small tubes can drain blood effectively.
In the case of malignant effusions, the fluid is often less viscous than acute blood. Small-bore tubes have a much easier time draining these fluids. Additionally, many malignant effusions are managed with an indwelling pleural catheter system that allows the patient to drain fluid at home. These catheters are small-bore by design and have revolutionized comfort and quality of life for patients.
Considerations and Caveats
Of course, no one-size-fits-all approach works in medicine. There may be certain clinical scenarios where a large-bore tube is still preferred. For example, if you suspect a massive hemothorax with very thick or clotted blood, or if you anticipate needing to evacuate large volumes very quickly (such as in a hemodynamically unstable trauma patient), a larger tube might still offer some advantages. The immediate flow rate might be better, and it might help surgeons or acute care physicians feel more confident that they won’t need to replace the tube or intervene again shortly.
However, for many routine cases—particularly stable patients with smaller volumes or malignant effusions—small-bore tubes seem to do just fine. The key is that clinical judgment should guide the decision. Think about the patient’s hemodynamic status, the nature of the fluid, the urgency of drainage, and the patient’s overall comfort and quality of life.
Changing Practice and Perception
Medicine is often influenced by tradition. For many years, “this is how we’ve always done it” was the motto. But as evidence builds and we realize that our beliefs don’t always hold up under scrutiny, guidelines and practices evolve. Many trauma centers, intensivists and pulmonologists have begun to integrate smaller tubes into their algorithms, especially for stable patients or those with recurrent malignant effusions.
This shift is more than just academic. It’s about patient-centered care. Smaller tubes generally mean less pain, potentially less sedation, and overall a better experience. They can also be easier for nursing staff and families to manage. Smaller devices can mean smaller scars, both literal and figurative.
Take-Home Message
So, does size matter when it comes to chest tubes for hemothorax and pleural effusions? The growing body of literature says: not as much as we once thought. Studies like those by Inaba et al. and Lyons et al. support small-bore tubes in traumatic hemothorax, showing no disadvantages in outcomes. Meanwhile, Thethi et al. and Parulekar et al. highlight the effectiveness of small-bore chest tubes for malignant pleural effusions. All told, small-bore chest tubes have a strong track record in terms of drainage efficacy, complication rates, and patient comfort.
That doesn’t mean we toss large-bore tubes out the window. In certain emergent settings, when rapid evacuation of a large volume of blood is needed, large-bore tubes may remain the go-to. But for many other scenarios, small-bore tubes are a perfectly viable—and sometimes preferable—option. As always, clinical judgment and individualized patient care should guide the decision.
Join the Conversation
Have you seen small-bore chest tubes used in your practice? Do you have stories—successful or challenging—regarding their use in trauma or malignant effusions? What factors influence your decision to pick one size over another? Share your thoughts in the comments below! We’d love to hear from you. Your insights can help us all continue to grow and learn together.
- Does Size Matter? A Prospective Analysis of 28-32 Versus 36-40 French Chest Tube Size in Trauma. Inaba K, Lustenberger T, Recinos G, et al. The Journal of Trauma and Acute Care Surgery. 2012;72(2):422-7. doi:10.1097/TA.0b013e3182452444. ↩︎
- Small Versus Large-Bore Thoracostomy for Traumatic Hemothorax: A Systematic Review and Meta-Analysis. Lyons NB, Abdelhamid MO, Collie BL, et al. The Journal of Trauma and Acute Care Surgery. 2024;97(4):631-638. doi:10.1097/TA.0000000000004412. ↩︎
- Effect of Chest Tube Size on Pleurodesis Efficacy in Malignant Pleural Effusion: A Meta-Analysis of Randomized Controlled Trials. Thethi I, Ramirez S, Shen W, et al. Journal of Thoracic Disease. 2018;10(1):355-362. doi:10.21037/jtd.2017.11.134. ↩︎
- Use of Small-Bore vs Large-Bore Chest Tubes for Treatment of Malignant Pleural Effusions. Parulekar W, Di Primio G, Matzinger F, Dennie C, Bociek G. Chest. 2001;120(1):19-25. doi:10.1378/chest.120.1.19. ↩︎