Chest Tube Management after Surgery for Pneumothorax

Abstract

Key Points: management of chest tubes after lung resection; Suction vs. no suction; regulated suction; management of chest tube after surgery for pneumothorax; regulated suction and recurrence 2 Synopsis:There is scant evidence on the management of chest tubes after surgery for pneumothorax. Most of the current knowledge is extrapolated from studies performed on lung cancer patients.We reviewed the existing literature on this subject with particular focus on the effect of suction and no suction on the duration of air leak after lung resection and surgery for pneumothorax.Moreover, we discussed the role of regulated suction, which seems to provide some benefit in reducing pneumothorax recurrence after bullectomy and pleurodesis.Finally we provided a personal view on the management of chest tubes after surgery for pneumothorax. 3 Management of chest tubes after lung resection A. Suction vs. no suctionThere are relative pros and cons in using suction versus no suction.Theoretically, suction promotes pleura-pleural apposition favoring the sealing of air leak and certainly favoring the drainage of large air leaks. However, suction has also been shown to increase the flow through the chest tube proportional to the level of suction applied (1) and it is assumed that this increased airflow increases the duration of drainage. Further, the use of suction has also historically, been associated with reduced patient mobilization, particularly if wall suction is used. On the other hand, the so called "no suction" or "alternate suction" approaches have been shown to be effective in some circumstances to reduce the duration of air leak (2,3,4), presumably by decreasing the air flow, whilst also favoring mobilization (since the patient is not attached to the wall suction). Nonetheless, the absence of suction makes this approach ineffective in case of medium to large air leaks (particularly in the presence of a large pneumothorax) (2) and to be associated with an increased risk of other complications (particularly pneumonia and arrhythmia) (5). Table 1 summary of the findings of the randomized trials published on suction versus no suction in lung resection patients.As evident from the table, these trials yielded mixed results. Some authors found a benefit by using "water seal" (2,3,7), others did not find any difference between the two modalities (5,6). 4The lack of objective data for more sensitive measurement of air leak severity has prevented the standardization of studies, and even test and control groups within studies, resulting in a lack of accurate quantification and reproducibility. B. Regulated SuctionSome new electronic chest drainage systems are now able to measure the pleural pressure. There is scant evidence on the role of pleural pressure on the healing of the lung parenchyma after surgery and duration of air leak.A recent paper has shown that the difference between minimum pressure and maximum pressure calculated from measurements taken during the 6 th postoperative hour following lobectomy was associated with the...

Facing the challenges of perioperative air leaks using water seal in Colombia

“…Although the clinical impact of this classification may be minimal, it provides clinicians with a general idea of the pleural fistula defect and status. 13–17…”

Persistent air leaks: a review with an emphasis on bronchoscopic management

“…There is not a current consensus on whether or not placing the chest tube to suction delays the time needed for the fistulous tract to heal. Some authors contend that water seal rather than active suction promotes healing of the alveolar-pleural fistula in pneumothorax by decreasing flow of air through the defect and thereby improving apposition of the lung tissue (19)(20)(21). Others believe that applying suction removes air from the pleural space at a rate greater than that of air leakage via the visceral pleural defect, promoting apposition between the visceral and parietal pleura thus enhancing healing (7,21).…”

“…Some authors contend that water seal rather than active suction promotes healing of the alveolar-pleural fistula in pneumothorax by decreasing flow of air through the defect and thereby improving apposition of the lung tissue (19)(20)(21). Others believe that applying suction removes air from the pleural space at a rate greater than that of air leakage via the visceral pleural defect, promoting apposition between the visceral and parietal pleura thus enhancing healing (7,21). Trials in the surgical literature that have evaluated suction vs water seal for post-operative air-leaks have yielded conflicting results, although it must also be noted that in these trials the air leaks were not necessarily persistent.…”

Single versus double chest drains after pulmonary lobectomy: a systematic review and meta-analysis

“…The purpose of placing closed chest drains after lobectomy is mainly to drain the blood and gas from the chest cavity and prevent regurgitation, to restore the normal negative pressure in the chest cavity, thereby promoting the lung expansion and prevent infections in the chest cavity [3]. The closed drainage can be used to observe whether there is active bleeding in postoperative patients, which is conducive to the recovery of postoperative pulmonary function and reduces the incidence of pulmonary infection [4,5]. Therefore, the management of chest drains after pulmonary lobectomy is crucial to the prognosis of patients.…”