Management of chest tubes after pulmonary resection: a systematic review and meta-analysis

Talbot, Max; Meunier, Bethann; Trottier, Vincent; Christian, Michael; Barber, Paul; Berger, Chris; McAlister, Vivian C.; Taylor, Scott D.

doi:10.1503/cjs.001411

Cited by 89 publications

(43 citation statements)

References 28 publications

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“…The only endpoint with a moderate level of quality evidence was the reduction in the incidence of residual pneumothorax when suction is applied after lung resection (16).…”

Section: B Regulated Suctionmentioning

confidence: 99%

Chest Tube Management after Surgery for Pneumothorax

Pompili

Salati

Brunelli

2017

Thoracic Surgery Clinics

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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...

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“…The only endpoint with a moderate level of quality evidence was the reduction in the incidence of residual pneumothorax when suction is applied after lung resection (16).…”

Section: B Regulated Suctionmentioning

confidence: 99%

Chest Tube Management after Surgery for Pneumothorax

Pompili

Salati

Brunelli

2017

Thoracic Surgery Clinics

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“…Based on anecdotal experience, it is generally accepted that negative pressure suction is required for effective drainage of post-operative effusions, adequate control of parenchymal air leaks, and expansion of the remaining lung (4,5). Two different pleural suction modalities are approved for use in Canada: a traditional analog constant suction system and a digital intermittent suction system.…”

Section: Introductionmentioning

confidence: 99%

Does the usage of digital chest drainage systems reduce pleural inflammation and volume of pleural effusion following oncologic pulmonary resection?—A prospective randomized trial

Waele¹,

Agzarian²,

Hanna³

et al. 2017

J. Thorac. Dis.

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Background: Prolonged air leak and high-volume pleural drainage are the most common causes for delays in chest tube removal following lung resection. While digital pleural drainage systems have been successfully used in the management of post-operative air leak, their effect on pleural drainage and inflammation has not been studied before. We hypothesized that digital drainage systems (as compared to traditional analog continuous suction), using intermittent balanced suction, are associated with decreased pleural inflammation and postoperative drainage volumes, thus leading to earlier chest tube removal. Methods: One hundred and three [103] patients were enrolled and randomized to either analog (n=50) or digital (n=53) drainage systems following oncologic lung resection. Chest tubes were removed according to standardized, pre-defined protocol. Inflammatory mediators [interleukin-1B (IL-1B), 6, 8, tumour necrosis factor-alpha (TNF-α)] in pleural fluid and serum were measured and analysed. The primary outcome of interest was the difference in total volume of postoperative fluid drainage. Secondary outcome measures included duration of chest tube in-situ, prolonged air-leak incidence, length of hospital stay and the correlation between pleural effusion formation, degree of inflammation and type of drainage system used.Results: There was no significant difference in total amount of fluid drained or length of hospital stay between the two groups. A trend for shorter chest tube duration was found with the digital system when compared to the analog (P=0.055). Comparison of inflammatory mediator levels revealed no significant differences between digital and analog drainage systems. The incidence of prolonged post-operative air leak was significantly higher when using the analog system (9 versus 2 patients; P=0.025). Lobectomy was associated with longer chest tube duration (P=0.001) and increased fluid drainage when compared to sublobar resection (P<0.001), regardless of drainage system. Conclusions: Use of post-lung resection digital drainage does not appear to decrease pleural fluid formation, but is associated with decreased prolonged air leaks. Total pleural effusion volumes did not differ with the type of drainage system used. These findings support previously established benefits of the digital system in decreasing prolonged air leaks, but the advantages do not appear to extend to decreased pleural fluid formation.

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“…These have shown to lead to shorter hospitalization, and lower overall costs without compromising standard of care. While prolonged air leak has been thoroughly studied in the context of lung resection, there is yet to be an established gold standard algorithm for management of high volume chest drain output [10] [12] [13]. Daily chest tube drainage greater than 250 milliliters (ml) is a commonly cited reason by surgeons for delayed discharge [11].…”

Section: Introductionmentioning

confidence: 99%

A Cross-Sectional Study: Chest Tube Drainage Practice Patterns among Canadian Thoracic Surgeons Following Pulmonary Surgery

Das¹,

Grant²,

Drewbrook³

et al. 2017

OJTS

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Background: High chest tube drainage following lung surgery is a rate-limiting step to discharge, increasing length of hospital stay. There is a paucity of evidence-based clinical research on safe maximal daily chest tube drainage prior to removal. Objectives: To describe the practice patterns of Canadian thoracic surgeons with respect to daily chest tube drainage after routine pulmonary surgery. Methods: A self-reported electronic questionnaire was administered to members of the Canadian Association of Thoracic Surgeons (CATS). Data was tabulated on the primary outcome of acceptable maximal daily pleural output prior to chest tube removal, and secondary outcomes of: years in clinical practice, academic versus community setting and rational for chest tube management. Descriptive and univariate analysis was conducted for each response by maximal daily pleural drainage category. Results: A total of 124 surveys were distributed. Response rate was 56%, with a 93% completion rate. Acceptable maximal pleural drainage among surgeons was highly variable. Rationale for tube removal was also variable, including individual clinical experiences (n = 23, 33%), evidence based guidelines (n = 18, 26%), and group practice pattern (n = 12, 17%). Academic surgeons comprised 72% of respondents. Community based surgeons were more likely to remove tubes at a lower mean volume. Years in clinical practice did not influence acceptable daily pleural drainage. Conclusion: There is great variability in post-operative management of chest tube fluid output among Canadian thoracic surgeons. Future research on this topic is warranted, with the aim of developing an evidence-based chest tube management algorithm incorporating daily chest tube drainage volumes as a key variable.

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Management of chest tubes after pulmonary resection: a systematic review and meta-analysis

Cited by 89 publications

References 28 publications

Chest Tube Management after Surgery for Pneumothorax

Chest Tube Management after Surgery for Pneumothorax

Does the usage of digital chest drainage systems reduce pleural inflammation and volume of pleural effusion following oncologic pulmonary resection?—A prospective randomized trial

A Cross-Sectional Study: Chest Tube Drainage Practice Patterns among Canadian Thoracic Surgeons Following Pulmonary Surgery

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