Chest
Volume 128, Issue 2, August 2005, Pages 816-820
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Clinical Investigations: SURGERY
The Management of Chest Tubes in Patients With a Pneumothorax and an Air Leak After Pulmonary Resection

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Background

Placing chest tubes to water seal is superior for patients with an air leak, but when a patient has a pneumothorax and an air leak the best chest tube setting is unknown

Methods

This is a retrospective analysis of a prospective database on a consecutive series of patients who had a pneumothorax and air leak on the same day. Patients underwent elective pulmonary resection by one surgeon and had their chest tubes placed to water seal on postoperative day 1. Daily chest radiographs were obtained, and the size of the pneumothorax and air leak were measured. Tubes were left on seal unless there was a symptomatic enlarging pneumothorax or subcutaneous emphysema (defined as failing water seal). The primary objective was to evaluate the efficacy of water seal. We also wanted to identify risk factors that predicted failure of water seal

Results

There were 838 patients ≥ 21 years old who underwent elective pulmonary resection, and 86 patients (10%) had an air leak and a concomitant pneumothorax on the same day. Fourteen patients (16%) failed water seal. Multivariate analysis showed that a large air leak (greater than or equal to expiratory 3 in our classification system; odds ratio [OR], 16.5; p < 0.001) and a pneumothorax > 8 cm in size (OR, 4.9; p < 0.005) were predictors of failing water seal

Conclusions

Keeping chest tubes on water seal is safe for most patients with an air leak and a pneumothorax. However, if the leak or pneumothorax is large, then subcutaneous emphysema or an expanding symptomatic pneumothorax is more likely. A prospective randomized trial is needed to compare water seal to suction in these patients

Section snippets

Inclusion Criteria

The study population consisted of 838 patients ≥ 21 years old who underwent elective pulmonary resection at the University of Alabama at Birmingham performed by a general thoracic surgeon (R.J.C.) over a 2-year period. Patients who underwent pneumonectomy, video-assisted thoracoscopic resection, or pulmonary resection performed as a part of a larger procedure (ie, decortication for empyema or Ivor Lewis esophagogastrectomy) were excluded. Data were collected prospectively, and the Institutional

Results

Table 1 compares the demographics, some previously identified risk factors for air leaks,5 and the type of surgery for these 86 patients. It also compares the 72 patients who tolerated water seal to the 14 patients who did not.

Variables associated with water seal failure were the diffusion capacity of the lung for carbon monoxide corrected for alveolar volume (Dlco/Va) [reported as percentage of the predicted value] < 60%, an air leak greater than or equal to expiratory 3, and a pneumothorax ≥

Discussion

The management of drains and tubes after many surgical procedures is highly variable.9 Few trials have been dedicated to these issues, and thus surgical opinion has become dictum. We have studied some of the various issues concerning chest tube management often using prospective randomized trials. We have tried to address one specific question at a time in a select group of consecutive patients who have undergone similar operations by one surgeon with similar preoperative, intraoperative, and

Appendix

The RDC classification system classifies an air leak based on when it occurs during the respiratory cycle (the qualitative aspect of the classification system) and how big the air leak is (the quantitative aspect of the system). Briefly, the RDC system labels air leaks as one of four types: continuous (occurring during inspiration and expiration), inspiratory, expiratory, or forced expiratory. A forced expiratory leak is present when a patient has no air leak detected with deep inspiration and

References (9)

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