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* From the Section of General Thoracic Surgery, Division of Cardiothoracic Surgery, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA.
Correspondence to: Joseph B. Shrager, MD, FCCP, Section of General Thoracic Surgery, 6th Floor Silverstein Building, University of Pennsylvania Medical Center, 3400 Spruce St, Philadelphia, PA 19104; e-mail: jshrag{at}mail.med.upenn.edu
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Abstract |
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Design: A prospective, randomized, controlled trial. After an initial, brief period of suction, patients were randomized to water seal or - 20 cm H2O suction.
Setting: University hospital.
Patients: Sixty-eight patients who underwent wedge resection, segmentectomy, or lobectomy were included in the study. Those patients who underwent reoperative surgery or lung volume reduction surgery were excluded.
Results: There were 34 patients in each group. The two groups were evenly matched for age, sex, operation performed, severity of lung disease, and nutritional status. Fifteen patients in each group (44%) had an air leak at the completion of surgery. The duration of the air leak was shorter in the water seal group than in the suction group (mean ± SEM, 1.50 ± 0.32 days vs 3.27 ± 0.80 days, respectively; p = 0.05). The mean times to removal of chest tubes were 3.33 ± 0.35 days in the water seal group and 5.47 ± 0.98 days in the suction group (p = 0.06). The length of stapled parenchyma was measured for each patient and averaged 24.9 cm for the water seal group and 18.5 cm for the suction group (p = 0.18). When corrected for the length of staple lines, the duration of air leaks and days with chest tube were dramatically lower in the water seal group (p = 0.02 and p = 0.02, respectively).
Conclusion: Placing chest tubes on water seal after a brief period of suction after pulmonary resection shortens the duration of the air leak and likely decreases the time that the chest tubes remain in place. Adoption of this practice may result in lower morbidity and lower hospital costs.
Key Words: chest tubes • postoperative complication • pulmonary • suction • surgical procedure • thoracic surgery • thoracostomy
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Introduction |
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Recently, thoracic surgeons have begun to perform pulmonary resections in patients with what would previously have been considered to be prohibitively decreased pulmonary function and dangerously fragile parenchymal tissue. After lung volume reduction surgery (LVRS), the prototype of this sort of procedure, it has been suggested that air leaks are prolonged by setting the chest tubes at the traditional - 20 cm of suction.10 11 Although this suggestion has never been subjected to a rigorous scientific evaluation, its truth has been recognized by experienced individuals in the pulmonary and thoracic surgical communities. Virtually all surgeons performing LVRS now manage chest tubes in these patients with water seal alone. This change in management seems to have played a role in the significant reductions in morbidity and mortality after LVRS.
In patients undergoing pulmonary resection other than LVRS, who may have relatively normal or compromised pulmonary function but rarely emphysema as severe as that of patients with LVRS, most surgeons continue to place chest tubes to suction in the traditional manner. Although, theoretically, placing chest tubes to suction improves apposition of the visceral and parietal pleurae and thus may lead to a shorter duration of air leaks, until recently this belief had never been objectively evaluated.12 13
On the basis of the experience with LVRS patients, we hypothesized that if suction is counterproductive for patients with severe emphysema, it may also be counterproductive for patients with more healthy lungs. Cerfolio et al12 tested a similar hypothesis and reported that patients who are routinely placed on water seal 2 days after a pulmonary operation resolve their air leaks earlier than patients who remain on suction. We designed a randomized, prospective study to take this concept a step further, evaluating whether placing patients routinely on water seal directly after surgery would shorten the duration of air leaks and the time to removal of chest tubes.
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Materials and Methods |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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Experimental Protocols
At the completion of the procedure, all patients initially had their chest tubes placed to - 20 cm suction in the operating room in an attempt to establish initial re-expansion of the lung. They were disconnected from suction for transfer to the recovery unit. On arrival in recovery, they were randomized to either remain on water seal or to be placed back on - 20 cm suction. All patients underwent chest radiography in the recovery unit.
For patients entered into the water seal protocol, if there was a > 25% pneumothorax on the radiograph in recovery or any subsequent radiograph (agreed on by two observers), they were converted to - 10 cm of suction until this space decreased to < 10%. They were then placed back on water seal. The housestaff checked for the presence of an air leak and altered management as appropriate twice daily, on morning and evening rounds. The chest tubes were removed when the air leak resolved and the drainage was < 300 mL/24 h.
Patients receiving the suction protocol had their chest drainage apparatus (Pleur-evac; Deknatel; Fall River, MA) connected to - 20 cm of suction from the completion of their operation with the exception of transfers. The presence of an air leak was checked twice daily, and the tubes were placed on water seal when the air leak ceased. As in the water seal group, the tubes were removed when the drainage was < 300 mL/24 h. Patients with air leaks that persisted for > 8 days were discharged with a Heimlich valve in place and seen twice weekly until the air leak ceased, at which time the chest tube was removed.
Exclusions
Patients who undergo reoperative surgery or lung volume reduction procedures were excluded from the study. We believed that the standard of care in LVRS patients has been established to include the use of water seal alone.
Randomization
Sixty-eight patients were enrolled in the study (Table 1
). Thirty-four patients were randomized to each group. Forty-nine percent were men, and 51% were women. The groups were evenly matched for age.
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With regard to the types of operations performed, the groups were also closely matched. In the water seal group, there were 10 patients with wedge resections and 24 patients with lobectomies, with 2 of the patients having an additional wedge resection performed. In the suction group, there were 6 wedge resections, 3 segmentectomies, and 25 lobectomies, with three of the patients having an additional wedge resection performed. All parenchymal divisions, whether for nonanatomic wedge resections, division of intersegmental planes during segmentectomies, or division of fissures during lobectomies, were performed with GIA stapling devices (United States Surgical; Norwalk, CT).
Statistical Analysis
Data are expressed as the mean ± SEM. Groups were compared using the independent samples t test with statistical significance as determined by p 
0.05. Data analyses were made using software (SigmaStat; SPSS; Chicago, IL).
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Results |
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Length of Staple Lines
To compare the length of stapled parenchyma for each patient in relation to the duration of air leaks and chest tube time, the number and size of staplers used were totaled. A total of 54 30-mm disposable stapler cartridges (Endo GIA 30 mm; United States Surgical) and 28 80-mm disposable stapler cartridges (GIA 80 mm; United States Surgical) were used for the water seal group. A total of 34 30-mm disposable stapler cartridges and 21 80-mm disposable stapler cartridges were used in the suction group. The average length of staples used per case in the water seal group was 24.9 ± 3.9 cm, and the average length of stapled parenchyma in the suction group was 18.5 ± 2.4 cm (p = 0.18).
Corrected Duration of Air Leak and Chest Tube Time
From the length of staple lines, we determined the duration of air leak and chest tube time per centimeters of staples. The corrected air-leak durations were highly significantly different at 0.080 ± 0.009 d/cm for the water seal group and 0.173 ± 0.002 d/cm for the suction group (p = 0.020). The corrected chest tube times were also dramatically different between the two groups at 0.174 ± 0.007 d/cm stapled parenchyma in the water seal group and 0.315 ± 0.002 d/cm stapled parenchyma in the suction group (p = 0.020).
Length of Stay
Lastly, the length of hospital stay was calculated for each subgroup with air leaks at the conclusion of their procedure. The range of hospital stay for the water seal group was 2 to 7 days (mean, 4.67 ± 0.37 days). The range of hospital stay for the suction group was 4 to 74 days (mean, 11.13 ± 4.58 days; p = 0.18).
Pneumothoraces
In the water seal group, four patients developed a pneumothorax > 25%, none of which caused any clinical compromise. These patients were placed on - 10 cm of suction according to the protocol. Within 24 h, all pneumothoraces were < 10% or completely resolved and the patients were then placed back on water seal without increase in the pneumothorax. No patient had a pneumothorax > 25% in the suction group. At the time of discharge, two patients in the water seal group and one patient in the suction group had small residual apical spaces. These were of no clinical significance and were entirely resolved by their first postoperative office visit 3 weeks after discharge.
One patient in the suction group with a preoperative FEV1 of 410 mL, receiving preoperative inhalers, steroids, and home oxygen, had a persistent air leak and was placed on a Heimlich valve. He was discharged on postoperative day 8. When this patient was evaluated in the office on postoperative day 11, the leak had sealed and the chest tube was removed.
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Discussion |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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The duration of air leaks in our water seal group was approximately one half of that observed in the suction group. This is consistent with the findings of Cerfolio et al,12 who cited that 66% of air leaks resolved on postoperative day 3 when tubes were placed on water seal on postoperative day 2, whereas only 7% of those kept on - 20 cm suction resolved the air leaks by day 3. Our patients, however, were placed on water seal at an earlier stage in their postoperative course (after only a 5- to 30-min period of suction) than in this previous study. Many would argue that placing thoracostomy tubes on suction is critical because it eliminates residual space and encourages early resolution of air leaks through pleural apposition. Because of our prestudy bias in favor of the importance of pleural apposition, we designed the water seal arm of the study to include at least a brief period of suction to provide a chance for initial apposition. We interpret our results as suggesting that, although pleural apposition may promote the sealing of air leaks, this must not be the only effect of chest tube suction, and other effects appear to negate this benefit.
Simple bedside observation of an air leak through the water seal chamber of a three-chamber drainage apparatus when it is connected to suction vs water seal can help one understand why suction in a patient with an air leak may in fact retard the sealing of that leak. When a patient has an air leak, the magnitude of the leak is considerably greater when the patient is connected to suction—that is, a leak visible only on forced expiration is often converted to a near-continuous leak by applying suction. This effect is often proportional to the amount of suction applied to the tube. With a decreased volume of air leaking from the parenchyma on water seal, healing and subsequent sealing of the leak by allowing cells to bridge the gap in the lung may occur more readily. Apparently, this benefit of water seal outweighs any negative effect of reduced pleural apposition.
Our data did not show a significant difference in the uncorrected duration of chest tubes for the two groups (p = 0.06); however, this variable did show a trend in favor of water seal, with the water seal group having a mean time of 3.33 days, 2 days shorter than the suction group. Notably, when corrected for length of staple lines, both duration of air leak and chest tube time became highly significantly different (p = 0.02 and p = 0.02, respectively) in favor of the water seal group. This would seem to be a valid correction to perform because staple lines are likely to be the major sources of air leaks in non-redo thoracotomies. Of the variables that we evaluated to determine whether the two groups were evenly matched for factors thought to predispose to leaks, only albumin and length of staple lines even approached statistical significance between groups.
The durations of hospital stay for each group were not significantly different, although there was a trend toward a shorter hospital stay in the water seal group. Many patients may have a longer stay related to reasons other than an air leak. However, we believe that with continued study, it is likely that one would show decreased hospital stay and decreased costs for patients placed on early water seal. One must take into account the fact that these patients do not have to be connected to a suction apparatus, they are able to ambulate more freely, and they require less nursing labor.
The patients placed on water seal in this study did have more pneumothoraces of significant size than the patients kept on suction. It is important to note, however, that none these pneumothoraces resulted in any clinical compromise—they were all discovered on radiographs in patients who were clinically well. Furthermore, all of these pneumothoraces were reduced to < 10% when the tubes were placed on - 10 cm suction, and with this intervention the entire water seal group still maintained its advantage over the suction group. At discharge, twice as many water seal patients as suction patients were left with a small, residual apical space; however, these were also of no clinical significance. These findings are also consistent with those of Cerfolio et al,12 13 in which 9 to 25% of patients placed on water seal had a small pneumothorax develop.
Because this study is relatively small, uncommon subgroups of patients in whom water seal may be of no benefit could have been overrepresented or underrepresented. It is therefore perhaps inappropriate to draw conclusions for these subgroups. For example, it is reasonable to hypothesize that patients with a significant component of restrictive lung disease may be at risk of having more frequent unresolved postoperative spaces if managed by our water seal protocol. We would not, therefore, recommend using our water seal protocol with such patients. Similarly, patients in whom there is believed to be more than the usual risk of postoperative bleeding may be best served by being placed on suction after operation to help maintain tube patency in the face of bloody drainage.
Finally, although we studied air leaks in the postoperative setting, it is reasonable to extrapolate from our results to other situations in which patients have thoracostomy tubes placed. For example, on the basis of our results, it is our current practice to place patients with spontaneous pneumothoraces or pneumothoraces after central line placement on water seal after a brief period of suction, with subsequent management as per the water seal protocol outlined herein. It is our clinical impression that leaks have resolved more quickly in these scenarios as well.
We conclude that placing patients on early water seal promotes the resolution of air leaks after pulmonary resection. This results in fewer days of air leak and a shorter time to chest tube removal per length of stapled parenchyma. We believe that further study will establish that use of early water seal also shortens hospital stay and lowers hospital costs. The data presented here, combined with previously reported data,12 13 as well as the lessons learned from the lung volume reduction surgery experience,10 11 provide compelling evidence that placing chest tubes on suction routinely after pulmonary resection is counterproductive.
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Footnotes |
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Received for publication May 15, 2001. Accepted for publication September 10, 2001.
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R. J. Cerfolio Invited commentary Ann. Thorac. Surg., June 1, 2004; 77(6): 1937 - 1937. [Full Text] [PDF]
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