Advances in thoracostomy tube management

Although air leaks are the most common complication after pulmonary resection, there has been a sparse amount of literature devoted to them. Moreover, a classification system for air leaks has never been devised until recently. Despite the fact that general thoracic surgeons make several decisions per day concerning the management of chest tubes, there has been little science devoted to this topic. For non-surgeons, the chest tube and the pleural space remain well-shrouded mysteries that are poorly understood and often mismanaged. Most surgeons decide how to manage tubes based on where and by whom they were trained as opposed to using objective data gathered from review of the most recent scientific literature. This fact is mainly because little to no scientific data have been generated. Studies of these problems in the author's institution over the past 5 years utilizing prospective randomized trials or predetermined algorithms have been performed to try to bring some science to what has always been a subjective art form. Accomplishments include the development and validation of an objective classification system for air leaks that is reproducible among observers. This system permits the accurate prediction of how long air leaks will last, which leaks should be treated with a water seal, which leaks are best treated with suction, and which patients will fail a Heimlich valve. The system can even predict on the first postoperative day which patients will have a prolonged leak and will require a Heimlich valve, regardless of chest tube management. This information has permitted the establishment of protocols that provide efficient chest tube management and contribute to fast-tracking patients after pulmonary resection, which enables patients to be discharged routinely with a high degree of satisfaction by postoperative day 3 or 4 [1]. This article summarizes several of these studies and describes current algorithms for chest tube management. The classification system, when to use wall suction, when to use water seal, and how to safely discharge patients by the fourth postoperative day-even with air leaks-are outlined. Conditions that permit safe removal of a chest tube-even in a patient who has a prolonged air leak and a pneumothorax-are described. Further details of chest tube management that are outside the scope of this chapter can be found elsewhere [2].