Pleural Interventions Research Articles

Current Trends in Treating Malignant Pleural Effusion: Evidence, Guidelines, and Best Practice Recommendations.

Malignant pleural effusion (MPE) is common in individuals with cancer and typically reflects advanced disease. Most cases are symptomatic, with dyspnea and pain having a severe effect on the patient's quality of life (QOL). The management of MPE aims to relieve symptoms, improve QOL, prevent repeated pleural interventions, and minimize hospital admissions. Common treatments for MPE that provide symptomatic relief include thoracentesis, chemical (talc) pleurodesis, or indwelling pleural catheters (IPCs). Talc pleurodesis and IPCs are the mainstay of treatment but represent very different treatment strategies: talc pleurodesis is an inpatient procedure, whereas IPCs are an ambulatory strategy. Given their similar efficacy, treatment decisions in MPE are often determined by other factors, such as the patient's clinical characteristics, individual treatment goals, and preferences for hospital-based or home-based care. We provide a summary of the evidence for different interventions for treating MPE and compare recommendations from the major American, European, British, and Spanish guidelines regarding when to consider each treatment. We highlight specific challenging treatment scenarios and key clinical considerations that may influence treatment decisions for different patients. There are barriers to accessing and receiving evidence-based care. Patients with symptomatic MPE would benefit from early referral from oncology teams to pleural services. We provide best practice recommendations for optimal referral and coordination of care to ensure that patients receive maximum benefits from their interventions.

Superimposed pleural infection in cirrhotic chylothorax.

Chylothorax contains an abundant amount of immunoglobulins and white blood cells, leading to the belief that superimposed pleural infection is unlikely. We report two cases of biochemically confirmed chylothorax due to cirrhosis, complicated by superimposed pleural infection following repeated pleural interventions. These findings highlight the potential for superimposed infection in chylothorax and challenge the belief in the bacteriostatic effect of chyle. Clinical vigilance is essential to consider this possibility if features of infection arise during the management of chylothorax.

Role of pleural manometry and transthoracic ultrasonography to predict entrapped lung

IntroductionUnexpandable lung is a complication by which the lung does not expand to the chest wall with pleural space drainage, which will result in adverse events or intervention failure if not well recognized prior to the intervention.Aim of the workThis study aimed to assess the role of pleural manometry and transthoracic ultrasonography in predicting abnormal lung expansion during pleural drainage.Patients and methodsThis was a prospective observational analytical study involving 50 patients that aims to predict abnormal lung expansion during pleural drainage using pleural manometry and transthoracic ultrasound.ResultsRegarding pleural manometry (pleural elastance), all patients in the entrapped lung group (100%) had pleural elastance > 14.5 cmH2o/L, while in the non-entrapped lung group, all patients (100%) had pleural elastance ≤ 14.5 cmH2o/L. Regarding ultrasonography, pleural thickening > 0.5 cm was found in all patients with entrapped lung (100%) and 50% of patients with non-entrapped lung with statistically significant difference. In the entrapped lung group, 20%, 35%, and 45% of patients had simple, complex non-septated, and complex septated pleural effusion, respectively, while in the non-entrapped lung group, 63.35%, 33.33%, and 3.32% of patients had simple, complex non-septated, and complex septated effusion, respectively, with statistically significant difference (p-value 0.0005).ConclusionPleural manometry and transthoracic ultrasound can guide decision-making regarding the timing of pleural interventions and management of cases with entrapped lung.

The burden of readmissions after rib fractures among older adults

BackgroundThe index hospitalization morbidity and mortality of rib fractures among older adults (aged ≥65 years) is well-known, yet the burden and risks for readmissions after rib fractures in this vulnerable population remain understudied. We aimed to characterize the burdens and etiologies associated with 3-month readmissions among older adults who suffer rib fractures. We hypothesized that readmissions would be common and associated with modifiable etiologies. MethodsThis survey-weighted retrospective study using the 2017 and 2019 National Readmissions Database evaluated adults aged ≥65 years hospitalized with multiple rib fractures and without major extrathoracic injuries. The main outcome was the proportion of patients experiencing all-cause 3-month readmissions. We assessed the 5 leading principal readmission diagnoses overall and delineated them by index hospitalization discharge disposition (home or facility). Sensitivity analysis using clinical classification categories characterized readmissions that could reasonably represent rib fracture-related sequelae. ResultsIn 2017, 25,092 patients met the inclusion criteria, with 20% (N = 4,894) experiencing 3-month readmissions. Six percent of patients did not survive their readmission. The 5 leading principal readmission diagnoses were sepsis (many associated with secondary diagnoses of pneumonia [41%] or urinary tract infections [41%]), hypertensive heart/kidney disease, hemothorax, pneumonia, and respiratory failure. In 2019, a comparable 3-month readmission rate of 23% and identical 5 leading diagnoses were found. Principal readmission diagnosis of hemothorax was associated with the shortest time to readmission (median [interquartile range]:9 [5–23] days). Among patients discharged home after index hospitalization, pleural effusion–possibly representing mischaracterized hemothorax–was among the leading principal readmission diagnoses. Some patients readmitted with a principal diagnosis of hemothorax or pleural effusion had these diagnoses at index hospitalization; a lower proportion of these patients underwent pleural fluid intervention during index hospitalization compared with readmission. On sensitivity analysis, 30% of 3-month readmissions were associated with principal diagnoses suggesting rib fracture-related sequelae. ConclusionReadmissions are not infrequent among older adults who suffer rib fractures, even in the absence of major extrathoracic injuries. Future studies should better characterize how specific complications associated with readmissions, such as pneumonia, urinary tract infections, and delayed hemothoraces, could be mitigated.

Conservative management versus invasive management of significant traumatic pneumothoraces in the emergency department (the CoMiTED trial): a study protocol for a randomised non-inferiority trial

IntroductionTraumatic pneumothoraces are present in one of five victims of severe trauma. Current guidelines advise chest drain insertion for most traumatic pneumothoraces, although very small pneumothoraces can be managed with...

Perioperative morbidity and 3-year survival in non-intubated thoracoscopic surgery: a propensity matched analysis.

Non-intubated thoracoscopic surgery with spontaneous breathing is rarely utilized, but may have several advantages over standard intubation, especially in those with significant cardiopulmonary comorbidities. In this study we evaluate the safety, feasibility, and 3-year survival of thoracoscopic surgery without endotracheal intubation for oncologic and non-oncologic indications. All consecutive patients [2018-2022] selected for lung resection or other pleural space intervention under local anesthesia and sedation were compared to a cohort undergoing elective thoracoscopic procedures with endotracheal intubation. A propensity-score matched cohort was used to compare perioperative outcomes and 3-year overall survival. A total of 72 patients underwent thoracoscopic surgery without intubation compared to 1,741 who were intubated. Non-intubated procedures included 19 lobectomies (26.4%), 9 segmentectomies (12.5%), 25 wedge resections (34.7%), and 19 pleural or mediastinal resections (26.4%). Non-intubated patients had a lower average body mass index (BMI; 24.6 vs. 27.1 kg/m2, P<0.001) and a higher comorbidity burden. Primary lung cancer was the indication in 30 (41.7%) non-intubated patients. The non-intubated cohort had no operative or 30-day mortality. After propensity-score matching, there was no significant difference in pre-operative factors. In propensity-score matched analysis, non-intubated patients had shorter median total operating room time (109 vs. 159 min, P<0.001) and procedure time (69 vs. 119 min, P<0.001). Peri-operative morbidity was rare and did not differ between intubated and non-intubated patients. There was no significant difference in 3-year survival associated with non-intubation in the propensity-score matched cohorts (95% vs. 89%, P=0.10) or in a Cox proportional hazard model [hazard ratio (HR), 1.15; 95% confidence interval (CI): 0.36-3.67; P=0.81]. Non-intubated thoracoscopic surgery is safe and feasible in carefully selected patients for both benign and oncologic indications.

Cardiac related pleural effusions: a narrative review.

Pleural effusions (PEs) are commonly seen in various pathologies and have a significant impact on patient health and quality of life. Unlike for malignant PEs, non-malignant PEs (NMPEs) do not have well-established guidelines. Much of the evidence base in this field is from a handful of randomised controlled trials (RCTs) and the majority are from retrospective cohort analyses and cases series. Cardiac related PEs fall within the entity of NMPEs and the aim of this narrative review is to gather the existing evidence in the field of congestive heart failure (CHF), pericarditis and post-cardiac injury syndrome (PCIS). This narrative review investigates the pathophysiology, diagnostic criteria and treatment options for the various cause of cardiac related PEs. This narrative review is based on a comprehensive literature search analysing RCTs, prospective and retrospective cohort analyses and published case series. CHF related PEs have a substantial mortality rate and carry a worse prognosis if the PEs are bilateral and transudative in nature. Light's criteria have often shown to misclassify transudative effusions in CHF (pseudo-exudates) and hence measuring serum-pleural albumin gradient is an invaluable tool to accurately identify transudates. Elevated serum and pleural N-terminal pro-B type natriuretic peptide (NT-proBNP) has shown increasing evidence of correctly identifying PEs secondary to CHF. However, they should be considered with the pre-test probability of CHF. Therapeutic thoracentesis and indwelling pleural catheter (IPC) placement may be necessary if medical management has failed. PEs can also occur secondary to pericarditis and are often small, bilateral and exudative. PCIS also results in PEs and are commonly seen in post-coronary artery bypass graft (CABG) surgery. Both entities need management of the underlying cause first, but in cases where PEs are refractory, individualised pleural interventions may be necessary. This comprehensive narrative review provides valuable insights into the aetiology, diagnosis and management of PEs secondary to CHF, pericarditis and PCIS. The aim is to enhance the clinicians' knowledge of this complex and controversial topic to improve patient care of cardiac-related PEs. Ongoing trials in this field will be able to provide valuable insights.

Hepatic hydrothorax.

Hepatic hydrothorax (HH) refers to the presence of a pleural effusion that develops in the context of underlying liver cirrhosis and portal hypertension. It carries a high risk of morbidity and mortality, with a median survival of 8-12 months. Diagnosis is usually confirmed by pleural aspiration, demonstrating typical features of a transudative effusion in the absence of co-existent cardio-pulmonary or renal pathology. The clinical presentation is quite variable, with some patients remaining relatively asymptomatic in the presence of small or incidental effusions, while others present with frank respiratory failure requiring pleural intervention. The development of spontaneous bacterial empyema (SBEM) is a significant and not infrequent complication, requiring prompt recognition and treatment. While the mainstay of management is focused on optimising fluid balance through dietary salt restriction and diuretic therapy, liver transplantation remains the definitive treatment option. As such, it is crucial to adopt a multi-disciplinary approach-involving pulmonologists, hepatologists, dieticians, and palliative care physicians-in order to optimise care for this often complex group of patients. This review will discuss the basic pathophysiology of HH, its clinical presentation and diagnosis, as well as the approach to management of HH in clinical practice, focussing on both interventional and non-interventional treatment modalities.

Деструктивные пневмонии у детей глазами телеконсультанта

Aim. To study problems that pediatricians face in the management of necrotizing pneumonia, and to show ways to its optimization. Materials and methods. Necrotizing pneumonia is a serious disease that causes difficulties in the choice of antibiotics, indications for pleural interventions and termination of the therapy. Although mostly pneumococcal, pneumonias with purulent cavities and methapneumonic pleurisy (immunopathologic in its origin) are clinically resistance to antimicrobials, and it is taken by pediatricians as indications for changing antibiotics and pleural taps. Hence the importance of studying the prevalent tactics. We conducted analysis of 52 tele-requests for children with pulmonary consolidation and air-filled cavities. Its share among all “general pediatric” requests increased from 5% in 2021–2022 to 18% in 2023–2024. Of 52 patients 43 had also pleural effusions, 11 — pneumothorax. Pneumonia followed measles in 6 children, pertussis in 3, scarlet fever — in 1. All diagnostic and curative actions were compared to Clinical guidelines. Results. In all instances conditions for hospital care (including intensive) were generally adequate, diagnostic activities were often redundant (nonrelevant analyses, multiple computer tomography instead of X-ray). Only 16 patients were started on cephtriiaxone and amoxicillin/ clavulanate recommended by Clinical guides, the rest received reserve antibiotics. All patients received the 2nd course (combinations of the reserve antibiotics), 20 of them also the 3rd course. Steroids were given only to 3 patients. Of 43 children with pleurisy taps or drainage had 33, only 9 of them according to indications. Conclusion. Pediatricians are not fully conversant with Clinical guides and it causes excessive administration of 2–3 courses of reserve antibiotics, unnecessary pleural interventions, infrequent use of steroid therapy that shortens the length of hospital stay. Keywords: necrotizing pneumonia, management optimization.

Clinical characteristics of chylothorax: results from the International Collaborative Effusion database.

Chylothorax is an uncommon medical condition for which limited data are available regarding the contemporary aetiology, management and outcomes. The goal of this study was to better define these poorly characterised features. The medical records of adult patients diagnosed with chylothorax at 12 centres across Europe, America and South Africa from 2009-2021 were retrospectively reviewed. Descriptive and inferential statistics were performed. 77 patients (median age 69 years, male to female ratio 1.5) were included. Subacute dyspnoea was the most typical presenting symptom (66%). The commonest cause of chylothorax was malignancy (68.8%), with lymphoma accounting for 62% of these cases. Other aetiologies were trauma (13%), inflammatory/miscellaneous conditions (11.7%) and idiopathic cases (6.5%). At the initial thoracentesis, the pleural fluid appeared milky in 73%, was exudative in 89% and exhibited triglyceride concentrations >100 mg·dL-1 in 88%. Lymphangiography/lymphoscintigraphy were rarely ordered (3%), and demonstration of chylomicrons in pleural fluid was never ascertained. 67% of patients required interventional pleural procedures. Dietary measures were infrequently followed (36%). No patient underwent thoracic duct ligation or embolisation. Morbidity included infections (18%), and thrombosis in malignant aetiologies (16%). The 1-year mortality was 47%. Pleural fluid protein >3.5 mg·dL-1 (sub-distribution hazard ratio (SHR) 4.346) or lactate dehydrogenase <500 U·L-1 (SHR 10.21) increased the likelihood of effusion resolution. Pleural fluid protein ≤3.5 mg·dL-1 (HR 4.047), bilateral effusions (HR 2.749) and a history of respiratory disease (HR 2.428) negatively influenced survival. Chylothoraces have a poor prognosis and most require pleural interventions. Despite the standard recommendations, lymphatic imaging is seldom used, nor are dietary restrictions followed.

Review of Image-Guided Pleural Interventions

Review of Image-Guided Pleural Interventions

Indwelling pleural catheters for persistent pleural effusions secondary to post lung resection for malignancies.

Malignant and nonmalignant pleural effusions (NMPEs) such as those due to hepatic hydrothorax have been successfully treated with an indwelling pleural catheter (IPC) with a low complication rate. There is no literature on the utility or safety of this treatment modality for NMPE post lung resection. We aimed to assess the utility of IPC for recurrent symptomatic NMPE secondary to post lung resection in lung cancer patients over a period of 4 years. Patients who underwent lobectomy or segmentectomy as part of the treatment plan for lung cancer between January 2019 and June 2022 were identified, these patients were screened for post-surgical pleural effusion. A total of 422 underwent lung resection, of which 12 had recurrent symptomatic pleural effusions requiring IPC placement and were selected for final analysis. The primary end points were improved symptomatology and successful pleurodesis. Mean time to IPC placement was 78.4 days post-surgery. The mean length of IPC catheter was 77.7 days standard deviation (SD) 23.8. All 12 patients achieved spontaneous pleurodesis (SP), there was no second pleural intervention or re-accumulation of fluid on follow up imaging in any of the subjects after IPC removal. Two patients (16.7%) had skin infection related to catheter placement that was managed with oral antibiotics, there were no cases of pleural infections that required catheter removal. IPC is a safe and effective alternative in managing recurrent NMPE post lung cancer surgery with high rate of pleurodesis and acceptable complication rates.

Implications of Pleural Fluid Composition in Persistent Pleural Effusion following Orthotopic Liver Transplant

Persistent pleural effusions (PPEf) represent a known complication of orthotopic liver transplant (OLT). However, their clinical relevance is not well described. We evaluated the clinical, biochemical, and cellular characteristics of post-OLT PPEf and assessed their relationship with longitudinal outcomes. We performed a retrospective cohort study of OLT recipients between 2006 and 2015. Included patients had post-OLT PPEf, defined by effusion persisting >30 days after OLT and available pleural fluid analysis. PPEf were classified as transudates or exudates (ExudLight) by Light's criteria. Exudates were subclassified as those with elevated lactate dehydrogenase (ExudLDH) or elevated protein (ExudProt). Cellular composition was classified as neutrophil- or lymphocyte-predominant. Of 1602 OLT patients, 124 (7.7%) had PPEf, of which 90.2% were ExudLight. Compared to all OLT recipients, PPEf patients had lower two-year survival (HR 1.63; p = 0.002). Among PPEf patients, one-year mortality was associated with pleural fluid RBC count (p = 0.03). While ExudLight and ExudProt showed no association with outcomes, ExudLDH were associated with increased ventilator dependence (p = 0.03) and postoperative length of stay (p = 0.03). Neutrophil-predominant effusions were associated with increased postoperative ventilator dependence (p = 0.03), vasopressor dependence (p = 0.02), and surgical pleural intervention (p = 0.02). In summary, post-OLT PPEf were associated with increased mortality. Ninety percent of these effusions were exudates by Light's criteria. Defining exudates using LDH only and incorporating cellular analysis, including neutrophils and RBCs, was useful in predicting morbidity.

The space between: pneumothorax or bulla

Background: Distinguishing between a bulla and pneumothorax can sometimes be difficult especially in the absence of preexisting lung disease, leading to inappropriate intervention. Case Presentation: We report the case of a well 32-year-old male who presented with a year&amp;apos;s history of insidious onset breathlessness. A routine chest radiograph was thought to show a large pneumothorax. He had chest drains placed with no radiological improvement. A video-assisted thoracic surgery procedure revealed a giant bulla. Conclusion: This case highlights the importance of correlating clinical assessment with radiological findings. Early Computerised Tomography (CT) imaging should be considered prior to pleural intervention in clinically stable patients.

250 POST-PERICARDIOTOMY SINDROME: A DESCRIPTIVE ANALYSIS OF A NEGLECTED SYNDROME

Abstract Background Post-pericardiotomy syndrome (PPS) is a condition in which the surgical incision of the pericardium provokes the onset of pericardial and/or pleural effusion as a result of the inflammatory response inside the pericardial and/or the pleural space. PPS is a common complication following cardiac surgery (CS) and it has a significant impact on post-surgical patients’ management. Thus, it would be useful to find predictors in order to stratify patients in terms of risk of PPS and define tailored Cardiovascular Rehabilitation (CR) programmes. Purpose The aim of this study was to assess the incidence and to elucidate the features of PPS in a population of patients undergoing cardiac surgery. Secondly, the study was focused on the findings of likeable predictors of PPS and PPS’ relapse. Methods A prospective cohort study was performed on 156 patients who underwent cardiac surgery and then were admitted to the CR Unit of our institute. Among the 156-patients population, 26 patients developed post-pericardiotomy syndrome. Pre-operative and post-operative anamnestic and clinical data were collected to define the baseline characteristics of the population. The predictive role of anamnestic data, type of surgical procedure and laboratory parameters was evaluated. Treatment was then started in the PPS population, analysed and compared to the outcome. Data were collected during CR hospital stay and after discharge, during follow up check-ups. During CR hospital stay, the analysis regarded first and second line medical therapy, which was started in case of persistence, worsening or relapse of the pericardial and/or pleural effusion. After discharge, the analysis considered the outcome of the therapy at a defined deadline. Binary logistic regression analysis was performed to identify possible predictors of PPS and PPS’ relapse. All the variables with a univariate p-value &amp;lt;0.150 or clinically relevant were entered into the multivariate model. Results The population comprehends 156 patients. PPS patients presented with pleural effusion pre surgical intervention in 3 cases (11.5% vs 0%; p-value &amp;lt; 0.001) and showed more frequently pericardial effusion early after surgery (53.8% vs 8.5%; p-value &amp;lt; 0.001). In 3 patients (1.9%) drainage of pleural effusion was needed (7.7% vs 0.8%, p-value= 0.019). At admission in the CR Unit 26 patients (16.6%) presented or subsequently developed PPS. Pericardial effusion was classified as mild in 18 patients (69.2%), moderate in 7 patients (26.9%) and severe in 1 patient (3.8%); the median value of pericardial effusion at diagnosis was 7.5 mm, while the median value of the maximum pericardial effusion was 9.5 mm. During in-hospital stay, a first line medical therapy was administered to 26 PPS patients (100%): 13 patients (50%) needed a switch to a second line therapy, 4 patients (15.4%) needed invasive treatment of the effusion, 3 patients (11.5%) needed percutaneous pleural drainage and 2 patients (7.7%) needed percutaneous pericardial drainage. Medical therapy’ collateral effects occurred in 7 patients (26.95%). PPS therapy at discharge was administered to 22 patients (84.6%). At follow up, pericardial effusion occurred in 9 patients (36%), pleural effusion occurred in 3 patients (12%). Relapse of pleuro/pericardial effusion after therapy suspension occurred in 3 patients (12%) and consequently, pleuro/pericardial effusion resolution was obtained in 23 patients (92%). The median time of therapy interruption at follow up was 27 days (7–60). Binary logistic regression was performed to identify the clinical predictors of PPS and PPS’ relapse, the multivariate analysis did not find statistical significance for independent predictors of both conditions. Conclusion The PPS is a common complication of cardiac surgery. Further studies are needed to determine novel possible PPS predictors. Possible indicators of PPS relapse should be identified in patients with possible discontinuation of treatment.

EE159 Economic Burden of Malignant Pleural Mesothelioma in Europe: A Systematic Literature Review

Despite recent improvements in the management of solid cancers, the survival rate in malignant pleural mesothelioma (MPM) remains low. Patients often need multiple pleural interventions to diagnose and manage the tumour, resulting in substantial economic burden. The objective of this systematic literature review (SLR) was to identify the cost and healthcare resource utilization (HRU) associated with MPM in Europe.

Indwelling pleural catheters for benign pleural effusions: a concise review.

Benign pleural effusions (BPEs) are more common than malignant effusions and their treatment involves treating the underlying disease process. However, in cases refractory to medical management, pleural interventions might be necessary. Use of indwelling pleural catheters (IPCs) has been gaining popularity for patients with refractory effusion. In this review, we will focus on reviewing the data assessing safety and efficacy of IPC in patients with BPE related to congestive heart failure (CHF), hepatic hydrothorax, end-stage renal disease (ESRD) and chylothorax. Several small studies including the most recent randomized control trial have looked into the efficacy and safety of IPC in BPE. Majority of data come from patients having CHF and hepatic hydrothorax as the underlying cause of the effusion. Limited data are available in patients with ESRD and chylothorax. Time to pleurodesis varies but is relatively higher in this patient population. Caution must be addressed in patients with immunocompromised status given a high risk of infection. IPCs are increasingly being used in patients with BPE refractory to medical management. They can be used both for palliation and to achieve pleurodesis in some cases. Further data in the form of randomized control trials are still needed to evaluate the efficacy and safety of its use in this patient population.

Cardiac-Device Implantation and Pneumothorax—A Symptom-Based Approach: Experience from a District General Hospital

In patients undergoing cardiac-device implantation, pneumothorax incidence occurs in 1–6%, and is more common in women over 80 years of age with chronic obstructive pulmonary disease (COPD). The aim of this study was to do a service review to identify ways to improve care delivery. Caldicott approval was gained. Those complicated by a pneumothorax were further analysed regarding basic demographics and pleural interventions and outcomes. Continuous variables are presented as mean (range) or median (with interquartile ranges) and categorical variables are presented as percentages where appropriate. A total of 2056 implantation episodes from January 2010 to December 2020 occurred with 70 pneumothoraxes (3.4%), which were all related to pacemaker insertion. The mean age was 68.1 years (17–97), 39 were female, and 31 were male. A total of 36 pneumothoraxes were small and were 34 large according to British Thoracic Society (BTS) criteria. We initially observed 56 patients with minimal or no symptoms (30 were large pneumothoraxes), with five requiring intercostal drainage (ICD). A total of 14 pneumothoraxes were treated with ICD as a first-line treatment: the mean age was 78 years (69–89) and eight patients had COPD. Five pneumothoraxes were large. All had significant symptoms. All pneumothoraxes resolved within six weeks with no associated mortality.

DRAINAGE MODALITIES IN PATIENTS WITH LUNG ABSCESS: A SINGLE CENTER EXPERIENCE

DRAINAGE MODALITIES IN PATIENTS WITH LUNG ABSCESS: A SINGLE CENTER EXPERIENCE

Chest Drainage Therapy: What Comes out of Pandora's Box Can Affect Patient Outcomes.

Background: Over the last 100 years, the original three-bottle chest drainage system has been variously engineered into compact disposables and electronic units. Clinicians are now surrounded by a plethora of different types of systems, but little is known about the way that they work and perform. Thus, we sought to test the performance of the most commonly used chest drainage units under conditions that are relevant to clinical practice. Methods: A pleural space environment simulator was built. Thirty-two units were tested under four clinical scenarios: air leak interpretation during quiet breathing and after obstructed inspiration (−5 to −150 cmH2O), a buildup of negative pressure (−100 cmH2O), a bronchopleural fistula (10 L/min) and the need for effective external suction in the presence of air leakage. Twenty-five units were “traditional” thoracic drainages, five were “digital” low-flow/low-vacuum pumps and two were hybrids (a combination of the two). According to the design of the seal and of the suction control, the units were classified as wet-wet, wet-dry and dry-dry. Results: All wet units showed reverse air flow, with the potential to mimic an air leak when there was none. Ten wet units showed no automatic negative pressure relief features, while five dry-dry did but were slow to react. Ten wet and five dry-dry units showed no capability to handle a 10 L/min leak, as they were restrictive to flow (peak pressure up to 55 cmH2O). Only seven dry-suction units were able to maintain the set suction at high airflow rates (>20 L/min). Conclusions: Different chest drainage unit designs lead to different performances, some of which may negatively impact patient outcomes. This sounds the call to tailor our clinical practice for the individual patient. A paradigm shift to better understand all components of pleural physiology post-surgical intervention on this relatively neglected topic is needed to improve our daily practice.