Because of the absence of prospective randomized trials comparing tubes of different sizes, some experts recommend5,29,47 initial drainage by large-bore tubes. Tubes as large as 28F, however, can be placed by CT scan-guided or US-guided percutaneous techniques, and image guidance appears to be the most important factor for successful drainage. Blind tube insertion has moderate success (< 50%) even with the placement of large-bore tubes.22,39,48 Solaini et al49 reported a lower success rate of 12% for unguided large-bore tubes for patients with ACCP stage 3 or 4 pleural infections. Failure is attributed to the misplacement of tubes distant from pleural locules, multiple noncommunicating locules, tube kinking, or obstruction by secretions. Complications, which include hemorrhage; perforation of the diaphragm, lung, or abdominal viscera; and tube misplacement into fissures or extrapleural tissue planes, develop in up to 20% of patients undergoing blind chest tube insertion.43 Blind chest tube insertion is now reserved for patients with large, free-flowing effusions at institutions that lack the resources for image-guided drainage.