Management of Patients With Persistent Air Leak After Elective Pulmonary Resection

Abstract

I read with interest the article by Cerfolio and colleagues [1Cerfolio R.J. Minnich D.J. Bryant A.S. The removal of chest tubes despite an air leak or a pneumothorax.Ann Thorac Surg. 2009; 87: 1690-1696Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar] regarding the safe removal of chest tubes in patients with persistent air leak or pneumothorax after elective pulmonary resection. A persistent air leak after elective pulmonary resection poses a difficult problem because maintaining prolonged negative suction on the chest drains to expand the affected lung may perpetuate the leak as well as restrict the patient's mobility, prolonged hospitalization, and risk of pleural space infection. The use of suctionless portable drainage device, as described by this article, permits the early discharge of patients, but does not eradicate the discomfort felt by patients due to the presence of chest drains or the risk of pleural space infection, not to mention the cost of using such devices. For the past 5 years, I have used a protocol to maintain my patients with persistent air leak on negative suction ranging from −20 cm H2O to maximum of −60 cm H2O to ensure full expansion of the affected lung for a fixed duration of 10 days. By 10 days, complete pleurodesis of the lung would have occurred, and the only remaining tract opened for air to escape is through the chest tube. After 10 days, patients are taken off suction at midnight and an anteroposterior chest roentgenogram is performed without suction on the morning of day 11. If the lung remains expanded, despite persistent air leak, or if there is an apical pneumothorax, provided the rest of the lung is adherent to the chest wall, the drain is removed in the morning. The pursestring around the chest drain wound is removed, and the wound is left open but covered by sterile gauze to allow for continual drainage of air or fluid. A repeat chest roentgenogram is obtained in the afternoon to confirm that the lung has remained expanded. Once this is confirmed, patients are generally discharged on the same day or the next day (postoperative day 12). Patients are followed up in the same week with a repeat chest roentgenogram to confirm expansion of the lung. I have used this protocol for the past 5 years in managing patients with persistent air leak; so far I have not encountered any significant major problems or the need to reinsert the chest drain or any occurrence of empyema. The majority of chest drain wounds and drain tracts are sealed by the time of the first follow-up, but this can take up to 2 weeks. Good wound care and daily dressing with sterile gauze ensures that the wound remains free of infection. Using this protocol, the majority of my patients with persistent air leak only stay for a maximum of 11 days postoperatively, after which the drains are removed and they are discharged. ReplyThe Annals of Thoracic SurgeryVol. 89Issue 2PreviewI congratulate Dr Chong on his study of air leaks [1] and urge him to continue to perform his work using a scientific method, and then to report his findings in an article in a peered-reviewed journal. We need more evidence-based medicine for chest tube management, and we greatly appreciate his experience. I have several questions and comments concerning his kind letter [1] in regard to our article [2]. Full-Text PDF