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Chest tube removal at the end of expiration with a stable Valsalva maneuver decreases the occurrence of clinically significant pneumothorax after pulling up drainages.
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Digital drainage systems allow differentiation of persisting air leak from pleural space effects when high differential pleural pressure and expiratory bubbling occurs.
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Digital drainage systems decrease the variability of the chest tube management in the clinical practice and help decrease the need of provocative clamping maneuvers.
When to Remove a Chest Tube
Section snippets
Key points
Introduction: how to remove a chest tube
Once a chest tube has been inserted, the most appropriate time for pulling it out is usually a matter of discussion because no sound evidence is available to construct evidence-based guidelines. Usually, chest tube withdrawal policies are dictated by personal preferences and experience, influencing quite variable lengths of stay for the same procedures.
The ideal respiratory phase (end of inspiration or expiration) for removing chest drainages is also debatable. From a physiologic point of view,
Does the patient have an air leak?
Postoperative air leak is a common clinical problem after lung surgery. It is dramatically influenced by the quality of the operated lung parenchyma. Because the occurrence of emphysema increases with age and surgeons are currently operating on older patients,4 the prevalence of the complication is expected to increase despite technical improvements. Postoperative air leak is considered an adverse postoperative event when patient discharge is consequently delayed or outpatient clinic checkups
Is provocative clamping still needed before chest tube removal?
There is no consensus on the actual benefits of digital compared with analogic drainage systems after lung resection. In their prospective randomized study, Gilbert and colleagues14 showed that digital drainage systems significantly decreased the number of clamping attempts. As previously mentioned,10 no provocative clamping test is necessary provided a digital continuous recording drainage device is used that shows that the patient is presenting with no air leak or changes in pleural
Is it possible to predict the occurrence of prolonged air leak?
Multiple factors are known to be linked to the risk of PAL. Probably, low forced expiratory volume in 1 second (FEV1) and diffuse emphysema are the most important ones, although important pleural adhesions, inflammatory chronic disease, and upper lobe lobectomy have also been suggested to have important roles.17 Recently, a nationwide retrospective study assessing this problem was released.18 After the analysis of more than 24,000 subjects, the investigators developed a predictive model based
Daily pleural drainage, a safe threshold for chest tube removal
Air leak is not the only limit to the possibility of chest tube removal, the quality and the amount of fluid are also crucial. Probably, the maximum daily pleural output is the parameter with the highest variability between surgeons (outputs ranging between 200 and 500 mL/24 h are admitted). Again, no evidence supports most of the current practices and agreement is necessary to establish an upper volume limit for a safe and efficient procedure. Of course, it is not arguable that the presence of
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Routine post-pull chest radiograph is not necessary after VATS lobectomy
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2021, Pleural Diseases: Clinical Cases and Real-World DiscussionsChest Wall Resection for Sarcoma: A Surgical Technique and Case Series
2020, Operative Techniques in OrthopaedicsCitation Excerpt :Chest tube removal is performed at end-expiration, and the skin incision is tied with the previously placed suture at time of surgery. There is no agreed upon consensus describing the parameters to ideal chest tube removal.22-26 Studies demonstrating output of over 450 mL/24 h can have the tube removed safely,22,25 although we prefer less than 50 mL per day as a safe benchmark.
Digital thoracic drainage: a new system to monitor air leaks in pediatric population
2019, Journal of Pediatric SurgeryCitation Excerpt :Traditional drainage system does not allow to easily distinguishing between these two situations [3]. This device has been used in adult population with good results [3,6–9] but to our knowledge there is only one previous study on the use in children [4]. In this study they used the digital system in 11 patients who underwent to pulmonary resection (7 lobectomy, 2 segmentectomy and 2 lobectomy plus segmentectomy).
Lung Ultrasound to Detect Residual Pneumothorax After Chest Drain Removal in Lung Resections
2018, Annals of Thoracic Surgery
Conflicts of Interest: The authors have no conflicts of interest to declare.