Management of Air Leaks in Chest Tubes

According to:  Cerfolio RJ, Bass CS, Pask AH, Katholi CR. Ann Thorac Surg. 2002 Jun;73(6):1727–30.

ASSESSING FOR AIR LEAKS

All patients with chest tube in place should be assessed quantitatively for one of four types of air leaks (listed in increasing severity):

1. Forced expiratory, occurs with coughing/valsalva

2. Expiratory, alveolar-pleural fistulas

3. Inspiratory, ventilated patients, bronchopleural fistula or alveolar-pleural fistula

4. Continuous, ventilated patient, true bronchopleural fistula

Use the number of chambers bubbling in a wet suction controlled, closed drainage for quantitative measure of leak

AIR LEAK RISK FACTORS

Persistent air leaks in 669 post-operative patients occurred most commonly in patients with the following characteristics:

-Male sex

-Steroid therapy

-History of lobectomy

Patients persistent air leaks were discharged with a home device and most had resolution of the air leak within 2 weeks.

WHAT ABOUT MANAGEMENT OF AIR LEAKS?

According to:  Carrillo EH et al. J Trauma. 2006;60(1):111–4.

case series of 13 consecutive patients over 2 years with persistent posttraumatic air leak >72 hrs, managed with VATS + sealant, 100% with chest tubes removed within 48 hrs

and: Cerfolio RJ, Minnich DJ, Bryant AS. Ann Thorac Surg. 2009 Jun;87(6):1690–4.

A retrospective cohort with 199 patients post-pulmonary resection with persistent air leaks, defined as an air leak present on postoperative day 4, showed that after 2 weeks on an outpatient suction-less device most patients have resolution of the air leak.  Even if the air leak or small PTX are still present after 2-3 weeks, chest tubes can be removed after this time if the patient is asymptomatic with no subcutaneous emphysema.

A SUGGESTED  MANAGEMENT ALGORITHM: 

persistent air leak (3-7 days; 5+ days per STS definition)

↓

[thoracic surgery consult]

↓

[instill sclerosant per chest tube (talc slurry, doxycycline, autologous blood patch)]

↓

VATS wedge resection +/- pleurodesis

AND FINALLY, HOW TO REMOVE THE CHEST TUBE:

Cerfolio RJ et al. J Thorac Cardiovasc Surg. 2013;145(6):1535–9. -

single-institution RCT assessing pull at end-inspiration (n=179) vs end-expiration (n=163), post-pull PTX in 35% of end-inspiration vs 20% of end-expiration (p=0.007); recommend pull at end-expiration with Valsalva

and: Goodman MD et al. Am J Surg. 2010;199(2):199–203.

case series of 608 chest tubes over 3 years, no CXR following removal is safe strategy in non-ventilated, mentally alert/communicative pts with clinical reassessment at 6 hrs

by: Laura Humphries, MD

Ben Ferguson, MD

Nadine Peart, MS4