REVIEW URRENT C OPINION
Chest tube management: state of the art Patrick Zardo, Henning Busk, and Ingo Kutschka
Purpose of review Chest tube protocols are still largely dictated by personal preferences and experience. A general lack of published evidence encourages individual decision-making and hinders the development of clear-cut guidelines. The aim of this review is to establish standardized procedures with recommendations for size and number of inserted tubes, ideal suction levels and duration of thoracostomy. Recent findings Novel digital drainage systems markedly reduce interobserver variability in air leak assessment and may thus shorten chest tube duration and overall hospital stay. Paired with a more aggressive stance that allows chest tube removal even with secretion quantities of 500 ml/day, new protocols need to be established. Summary Thoracic procedures are heterogeneous and postsurgical requirements vary in accordance. Most resections will not require more than one large bore (20F) catheter and will benefit from postoperative active suction. Even though only moderate-quality evidence suggests that suction reduces incidence of pneumothorax if compared to water seal and its effects on prolonged air leak are controversial, recent studies encourage application of active suction. Removal of chest tubes appears to be well tolerated even with a secretion of above 450 ml/day. Keywords air leak, chest tube protocol, thoracic surgery
INTRODUCTION Even though chest tube management is generally considered a basic skill amongst thoracic surgeons, controversies as to optimal postsurgical treatment modalities abound [1,2,3 ]. A lack of published evidence encourages individual decision-making and hinders the development of clear-cut guidelines to standardize size and number of inserted tubes, ideal suction levels or duration of thoracostomy. As reliable empiric guidelines are known to streamline postoperative recovery, shorten intrahospital stay and reduce overall costs, establishing ‘chest tube protocols’ has become a priority for most thoracic surgery units. This endeavor has been facilitated by the advent of novel digital drainage devices capable of regulating intrapleural pressure levels and allowing exact air leak quantification [4 ,5]. Establishing simple guidelines for chest tube management is an arduous task, and numerous considerations have to be made. Thoracic procedures are heterogeneous and postsurgical requirements vary in accordance. Whereas most sublobar anatomical and extra-anatomical resections are often completed with implementation of just one catheter, decortication for stage III pleural empyema &
may necessitate as much as three large bore chest tubes. And while small and/or soft tubes start to replace stiff catheters in pediatric patients to reduce postoperative pain, most adults receive traditional large bore tubes to avoid dislodgement or clotting. To complicate matters further, chest drainage suction remains controversial, and some conservative surgeons still prefer a conventional water seal over novel digital systems. As most studies dealing with chest tube management in thoracic surgery circumvent above mentioned confounders by solely examining adult patients undergoing anatomical lobectomy, we will focus our review accordingly. Nonetheless, we will try to delineate objective treatment and management guidelines for different thoracic pathologies.
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Division of Cardiothoracic Surgery, Magdeburg University Hospital, Magdeburg, Germany Correspondence to Patrick Zardo, Magdeburg University Hospital, Division of Cardiothoracic Surgery, Leipziger Strasse 44, 39120 Magdeburg, Germany. Tel: +49 3916714100; fax: +49 3916714127; e-mail: [email protected] Curr Opin Anesthesiol 2015, 28:45–49 DOI:10.1097/ACO.0000000000000150
0952-7907 Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.co-anesthesiology.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Thoracic anesthesia
KEY POINTS One large bore chest tube will suffice for most of the thoracic procedures.
In the end, chest tubes still abide by the physics of Poiseuille’s law for fluids and the Fanning equation for air, so that an increase in tube diameter leads to greater flow of fluid and air [10 ]. As postoperatively larger (>500 ml) and potentially hemorrhagic (hematocrit of pleural fluid 50% of peripheral hematocrit) secretions with clot formation have to be expected, surgeons generally prefer large-bore catheters. Additionally, prolonged air leak is one of the most common complications after lung surgery [3 ]. When it occurs, air evacuation by small-bore Blake tubes tends to be insufficient, irrespective of suction conditions [17]. As many other institutions [18], we prefer 28-F tubes for most procedures, the only notable exception being empyema surgery, in which cases 32-F catheters are chosen. &
Suction remains controversial in air leak management, but still is central to avoiding and treating pneumothoraces. Chest tube removal appears to be well tolerated even with a daily secretion of above 450 ml.
&
BACKGROUND Chest tubes are indwelling catheters placed into the pleural space to evacuate abnormal collections of air or fluids and maintain a physiological negative intrapleural pressure. Evolutionary steps led from rigid metal tubes, as first described by Hippocrates of Kos (c. 460–370 BC) in empyema treatment almost 2500 years ago, to flexible polyvinyl chloride catheters utilized nowadays. Indications for chest tube placement include pneumothorax [6], pleural effusion [7], chylothorax, empyema [8], trauma [9] and postsurgical management after pulmonary and/or cardiac surgery [1,2,3 ]. &
SIZE By definition, the size of a chest tube refers to its outer diameter and is given in ‘French’ (F) or ‘Charrie`re’ (Ch), with 3 F corresponding to 1 mm [10 ]. Thus, a 24-F tube has an outer diameter of 8 mm. A general distinction between small-bore (1500 ml/min) are encountered does our protocol switch to standard water seal without suction. Patients undergoing pneumonectomy are the only notable exception and do not require active suction at any point. &&
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SECRETION In the absence of air leak (leakage
Chest tube management: state of the art Patrick Zardo, Henning Busk, and Ingo Kutschka
Purpose of review Chest tube protocols are still largely dictated by personal preferences and experience. A general lack of published evidence encourages individual decision-making and hinders the development of clear-cut guidelines. The aim of this review is to establish standardized procedures with recommendations for size and number of inserted tubes, ideal suction levels and duration of thoracostomy. Recent findings Novel digital drainage systems markedly reduce interobserver variability in air leak assessment and may thus shorten chest tube duration and overall hospital stay. Paired with a more aggressive stance that allows chest tube removal even with secretion quantities of 500 ml/day, new protocols need to be established. Summary Thoracic procedures are heterogeneous and postsurgical requirements vary in accordance. Most resections will not require more than one large bore (20F) catheter and will benefit from postoperative active suction. Even though only moderate-quality evidence suggests that suction reduces incidence of pneumothorax if compared to water seal and its effects on prolonged air leak are controversial, recent studies encourage application of active suction. Removal of chest tubes appears to be well tolerated even with a secretion of above 450 ml/day. Keywords air leak, chest tube protocol, thoracic surgery
INTRODUCTION Even though chest tube management is generally considered a basic skill amongst thoracic surgeons, controversies as to optimal postsurgical treatment modalities abound [1,2,3 ]. A lack of published evidence encourages individual decision-making and hinders the development of clear-cut guidelines to standardize size and number of inserted tubes, ideal suction levels or duration of thoracostomy. As reliable empiric guidelines are known to streamline postoperative recovery, shorten intrahospital stay and reduce overall costs, establishing ‘chest tube protocols’ has become a priority for most thoracic surgery units. This endeavor has been facilitated by the advent of novel digital drainage devices capable of regulating intrapleural pressure levels and allowing exact air leak quantification [4 ,5]. Establishing simple guidelines for chest tube management is an arduous task, and numerous considerations have to be made. Thoracic procedures are heterogeneous and postsurgical requirements vary in accordance. Whereas most sublobar anatomical and extra-anatomical resections are often completed with implementation of just one catheter, decortication for stage III pleural empyema &
may necessitate as much as three large bore chest tubes. And while small and/or soft tubes start to replace stiff catheters in pediatric patients to reduce postoperative pain, most adults receive traditional large bore tubes to avoid dislodgement or clotting. To complicate matters further, chest drainage suction remains controversial, and some conservative surgeons still prefer a conventional water seal over novel digital systems. As most studies dealing with chest tube management in thoracic surgery circumvent above mentioned confounders by solely examining adult patients undergoing anatomical lobectomy, we will focus our review accordingly. Nonetheless, we will try to delineate objective treatment and management guidelines for different thoracic pathologies.
&&
Division of Cardiothoracic Surgery, Magdeburg University Hospital, Magdeburg, Germany Correspondence to Patrick Zardo, Magdeburg University Hospital, Division of Cardiothoracic Surgery, Leipziger Strasse 44, 39120 Magdeburg, Germany. Tel: +49 3916714100; fax: +49 3916714127; e-mail: [email protected] Curr Opin Anesthesiol 2015, 28:45–49 DOI:10.1097/ACO.0000000000000150
0952-7907 Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.co-anesthesiology.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Thoracic anesthesia
KEY POINTS One large bore chest tube will suffice for most of the thoracic procedures.
In the end, chest tubes still abide by the physics of Poiseuille’s law for fluids and the Fanning equation for air, so that an increase in tube diameter leads to greater flow of fluid and air [10 ]. As postoperatively larger (>500 ml) and potentially hemorrhagic (hematocrit of pleural fluid 50% of peripheral hematocrit) secretions with clot formation have to be expected, surgeons generally prefer large-bore catheters. Additionally, prolonged air leak is one of the most common complications after lung surgery [3 ]. When it occurs, air evacuation by small-bore Blake tubes tends to be insufficient, irrespective of suction conditions [17]. As many other institutions [18], we prefer 28-F tubes for most procedures, the only notable exception being empyema surgery, in which cases 32-F catheters are chosen. &
Suction remains controversial in air leak management, but still is central to avoiding and treating pneumothoraces. Chest tube removal appears to be well tolerated even with a daily secretion of above 450 ml.
&
BACKGROUND Chest tubes are indwelling catheters placed into the pleural space to evacuate abnormal collections of air or fluids and maintain a physiological negative intrapleural pressure. Evolutionary steps led from rigid metal tubes, as first described by Hippocrates of Kos (c. 460–370 BC) in empyema treatment almost 2500 years ago, to flexible polyvinyl chloride catheters utilized nowadays. Indications for chest tube placement include pneumothorax [6], pleural effusion [7], chylothorax, empyema [8], trauma [9] and postsurgical management after pulmonary and/or cardiac surgery [1,2,3 ]. &
SIZE By definition, the size of a chest tube refers to its outer diameter and is given in ‘French’ (F) or ‘Charrie`re’ (Ch), with 3 F corresponding to 1 mm [10 ]. Thus, a 24-F tube has an outer diameter of 8 mm. A general distinction between small-bore (1500 ml/min) are encountered does our protocol switch to standard water seal without suction. Patients undergoing pneumonectomy are the only notable exception and do not require active suction at any point. &&
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&
SECRETION In the absence of air leak (leakage
![[Chest tube management following lung resections].](/assets/img/hold.png)
