From tradition to evidence: a narrative review for standardizing chest tube management after anatomic lung resection

Chest tube insertion after lung resection has been standard practice to facilitate lung re-expansion and reduce surgical complications. Historically, chest tube management has been left to institutional practices. The European Society of Thoracic Surgeons published thoracic specific enhanced recovery after surgery (ERAS) guidelines in 2019, providing a 45-item list of recommendations. However, many questions about the optimal management of chest tubes were left unanswered. In 2024, the Society of Thoracic Surgeons published an expert consensus consisting of 13 recommendations specifically for post-lobectomy drain management. However, as our study background highlights, these guidelines were based on heterogenous levels of evidence with room for further guidance. The study objective of this review article is to evaluate several key topics to provide an evidence-based comprehensive management strategy for chest tubes after lobectomy.

We performed a narrative review of literature evaluating chest tube management following anatomic lung resection. Publications accessed via PubMed from 2015 to February 15, 2026 were considered for their relevance to the topic, including: systematic and narrative reviews, consensus statements, randomized controlled trials, and society guidelines. Recommendations regarding chest tube number and size, digital versus analog drainage systems, suction or water seal strategies, imaging timing, removal criteria, postoperative air leak management, and ERAS pathway integration were all examined. We used the Centre for Evidence-Based Medicine as a guide for grading each recommendation.

Current evidence supports the use of a single tube after lung resection, avoiding external suction, and allowing tube removal with drainage volumes of 450-500 mL/day. Digital drainage systems reduce bias in air leak assessment and variability in management decisions. Routine scheduled chest X-rays may not be necessary in the stable patient. Early chest tube removal and selected chest tube omission may be considered as safe and associated with reduced pain and hospital length of stay.

Chest tube management remains a crucial determinant in recovery after anatomic lung resection. Current evidence supports standardized ERAS-protocols which emphasize early chest tube removal, reduced imaging, and objective air leak assessment. Adoption of evidence-based guidelines on chest tube management after anatomic lung resection improve patient outcomes while simultaneously reducing practice variability.