Should chest drains be put on suction or not following pulmonary lobectomy
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《血管的通路杂志》
a Department of Cardiothoracic Surgery, Freeman Hospital, Freeman Road, Newcastle upon Tyne, NE7 7AZ, UK
b Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
Abstract
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether the use of suction applied to chest drains in patients undergoing lobectomy reduces the incidence of prolonged air leak. Altogether 391 papers were found using the reported search, of which 6 represented the best evidence on this topic, including 5 well conducted prospective randomised controlled trials. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We conclude that of the 6 studies presented, no studies found in favour of suction to reduce the incidence of air leak, 2 studies found no difference between the two strategies, and 4 studies found evidence that water seal drainage without suction reduced the incidence of air leak. Five of the 6 studies used a short period of suction in the immediate post-operative period and the one study looking at immediate water seal drainage found no differences in outcome. Exceptions to the water seal strategy may be patients with a large air leak, or a large pneumothorax on CXR.
Key Words: Evidence based medicine; Suction; Chest tubes; Drainage; Lobectomy; Thoracic surgery
1. Introduction
A best evidence topic was constructed according to a structured protocol. This protocol is fully described in the ICVTS [1].
2. Clinical scenario
You are on your ward round and you see a fit 51-year-old gentleman 3 days post right upper lobectomy. He has an air leak. He asks why he is not allowed to go to the toilet or go for a walk with the physiotherapist like everyone else on the ward. You tell him that the only way to resolve the air leak is to use suction. He mumbles that it is probably making it worse. You resolve to search the literature to see if he is right.
3. Three-part question
In [patients undergoing pulmonary procedures] is the use of [suction to the chest drains] of benefit in reducing the incidence of [prolonged air leak]
4. Search strategy
Medline 1996–Jan 2006 using the OVID interface [lobectom$.mp/OR pulmonary resection.mp OR lung resection.mp OR pulmonary surgery.mp OR VATS.mp OR exp Thoracic surgery, Video-assisted/OR Thoracoscopy/OR thoracoscopy.mp] and [exp suction/OR suction.mp OR exp Chest tubes/OR exp Drainage/OR chest tube$.mp OR chest drain$.mp OR water seal.mp] and [air leak$.mp OR exp ‘length of stay’/OR hospital stay.mp OR pneumothorax.mp OR exp Pneumothorax/].
5. Search outcome
A total of 391 abstracts were found of which six were directly relevant. These are presented in Table 1. In addition, two papers were of interest although not tabulated.
6. Results
Five randomised controlled trials and one single centre cohort study were identified which investigated the effect of using chest drain suction or water seal drainage in patients following pulmonary procedures.
Alphonso and Treasure et al. [1] in 2005 performed a prospectively randomised controlled trial of 239 patients either to suction or water seal drainage following pulmonary procedures (mainly lobectomy or wedge resection). There was persistent air leak (lasting more than six days) in 7.8% of patients in the suction group and 10.1% of patients in the non-suction group. This difference was not significant. In addition, there was no difference in air leak persistence on any of the previous 6 days. Of note this is the only study of the five that randomised patients immediately after the operation. As a result of this study, a policy of underwater seal drainage only has been adopted at Guy's Hospital in London.
Brunelli et al. [2] in 2004 randomised 145 patients post-lobectomy who developed an air leak on the first postoperative day. The chest tubes were placed either on water seal or on 20 cm H2O continuous suction. No significant differences were found between the two groups in terms of duration of air leak (6.5 days vs. 6.3 days) and the incidence of prolonged air leak (27.8% vs. 30.1%). There was an almost significant increase in all postoperative complications, when water seal was compared to the suction group (31.9% vs. 17.8%, P=0.056). Obscurely, as a result of this study, the authors decided to institute a policy of 10 cm H2O suction at night and no suction in the day for their institution.
Ayed [3] in 2003 performed a randomised trial in Kuwait on 100 consecutive patients undergoing thoracoscopy for primary spontaneous pneumothorax. Patients were assigned into two groups to receive suction or water seal to their chest tubes after 2 h of suction. Fourteen percent of patients in the suction group had prolonged air leak compared to 2% of those in the water seal group. Also, the duration of chest tube days in-situ and hospital stay was lower in the water seal group (2.7 days) compared to the suction group (3.8 days). These results were found to be statistically significant.
Marshall et al. [4] in 2002 randomised 68 patients who underwent wedge resection, segmentectomy or lobectomy into a water seal group or suction group after return to the recovery room and a CXR while on suction. When corrected for staple lines, the duration of air leak (0.08 days vs. 0.17 days) and mean times to removal of chest tubes (0.17 days vs. 0.32 days) were significantly lower in the water seal group compared to the suction group. Hospital stay was also significantly shorter in the water seal group.
Cerfolio et al. [5–8] have published multiple papers addressing the issue of air leaks in thoracic patients, including the production of an algorithm and an air leak classification system. In their prospective randomised controlled trial, 33 patients who developed an air leak following pulmonary resection were assigned to either suction or water seal 48 h post surgery. Prolonged air leak (lasting more than 3 days) was found to be significantly reduced in the water seal only group with 12 of 18 stopping compared to only 1 out of 15 in the suction group. In addition, they described a 7-point air leak scale and in their study, all 6 persistent air leak patients had a score of 4 or more.
Antanavicius et al. [9] in 2005 retrospectively reviewed the duration of chest drains and hospital stay in 109 consecutive patients that underwent pulmonary procedures in their hospital in Pittsburgh, USA. Most patients with a post-operative air leak received suction but if no air leak was present, half of the patients tended to have no suction. (Decision was based entirely on surgeon's preference and was not randomised.) Chest tube and hospital stay duration were significantly lower in the no suction groups.
7. Conclusion
Of the six studies presented, no studies found in favour of suction to reduce the incidence of air leak, two studies found no difference between the two strategies, and four studies found evidence that water seal drainage without suction reduced the incidence of air leak. Five of the six studies used a short period of suction in the immediate post-operative period and the one study looking at immediate water seal drainage found no differences in outcome. Exceptions to the water seal strategy may be patients with a large air leak, or a large pneumothorax on CXR.
References
Alphonso N, Tan C, Utley M, Cameron R, Dussek J, Lang-Lazdunski L, Treasure T. A prospective randomised controlled trial of suction versus non-suction to the under-water seal drains following lung resection. Eur J Cardiothorac Surg 2005; 27:391–394.
Brunelli A, Monteverde M, Borri A, Salati M, Marasco RD, Al Refai M, Fianchini A. Comparison of water seal and suction after pulmonary lobectomy: a prospective, randomised trial. Ann Thorac Surg 1937; 77:1932–1937. discussion. p. 1937.
Ayed AK. Suction versus water seal after thoracoscopy for primary spontaneous pneumothorax: prospective randomised study. Ann Thorac Surg 2003; 75:1593–1596.
Marshall MB, Deeb ME, Bleier JI, Kucharczuk JC, Friedberg JS, Kaiser LR, Shrager JB. Suction versus water seal after pulmonary resection: a randomised prospective study. Chest 2002; 121:831–835.
Cerfolio RJ, Bass C, Katholi CR. Prospective randomised trial compares suction versus water seal for air leaks. Ann Thorac Surg 2001; 71:1613–1617.
Cerfolio RJ, Bryant AS, Singh S, Bass CS, Bartolucci AA. The management of chest tubes in patients with a pneumothorax and an air leak after pulmonary resection. Chest 2005; 128:816–820.
Cerfolio RJ. Recent advances in the treatment of air leaks. Curr Opin Pulm Medicine 2005; 11:319–323.
Cerfolio RJ, Tummala RP, Holman WL. A prospective algorithm for the management of air leaks after pulmonary resection. Ann Thorac Surg 1998; 66:1726–1731.
Antanavicius G, Lamb J, Papasavas P, Caushaj P. Initial chest tube management after pulmonary resection. Am Surgeon 2005; 71:416–419.(Aliu Sanni, Adam Critchle)
b Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
Abstract
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether the use of suction applied to chest drains in patients undergoing lobectomy reduces the incidence of prolonged air leak. Altogether 391 papers were found using the reported search, of which 6 represented the best evidence on this topic, including 5 well conducted prospective randomised controlled trials. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We conclude that of the 6 studies presented, no studies found in favour of suction to reduce the incidence of air leak, 2 studies found no difference between the two strategies, and 4 studies found evidence that water seal drainage without suction reduced the incidence of air leak. Five of the 6 studies used a short period of suction in the immediate post-operative period and the one study looking at immediate water seal drainage found no differences in outcome. Exceptions to the water seal strategy may be patients with a large air leak, or a large pneumothorax on CXR.
Key Words: Evidence based medicine; Suction; Chest tubes; Drainage; Lobectomy; Thoracic surgery
1. Introduction
A best evidence topic was constructed according to a structured protocol. This protocol is fully described in the ICVTS [1].
2. Clinical scenario
You are on your ward round and you see a fit 51-year-old gentleman 3 days post right upper lobectomy. He has an air leak. He asks why he is not allowed to go to the toilet or go for a walk with the physiotherapist like everyone else on the ward. You tell him that the only way to resolve the air leak is to use suction. He mumbles that it is probably making it worse. You resolve to search the literature to see if he is right.
3. Three-part question
In [patients undergoing pulmonary procedures] is the use of [suction to the chest drains] of benefit in reducing the incidence of [prolonged air leak]
4. Search strategy
Medline 1996–Jan 2006 using the OVID interface [lobectom$.mp/OR pulmonary resection.mp OR lung resection.mp OR pulmonary surgery.mp OR VATS.mp OR exp Thoracic surgery, Video-assisted/OR Thoracoscopy/OR thoracoscopy.mp] and [exp suction/OR suction.mp OR exp Chest tubes/OR exp Drainage/OR chest tube$.mp OR chest drain$.mp OR water seal.mp] and [air leak$.mp OR exp ‘length of stay’/OR hospital stay.mp OR pneumothorax.mp OR exp Pneumothorax/].
5. Search outcome
A total of 391 abstracts were found of which six were directly relevant. These are presented in Table 1. In addition, two papers were of interest although not tabulated.
6. Results
Five randomised controlled trials and one single centre cohort study were identified which investigated the effect of using chest drain suction or water seal drainage in patients following pulmonary procedures.
Alphonso and Treasure et al. [1] in 2005 performed a prospectively randomised controlled trial of 239 patients either to suction or water seal drainage following pulmonary procedures (mainly lobectomy or wedge resection). There was persistent air leak (lasting more than six days) in 7.8% of patients in the suction group and 10.1% of patients in the non-suction group. This difference was not significant. In addition, there was no difference in air leak persistence on any of the previous 6 days. Of note this is the only study of the five that randomised patients immediately after the operation. As a result of this study, a policy of underwater seal drainage only has been adopted at Guy's Hospital in London.
Brunelli et al. [2] in 2004 randomised 145 patients post-lobectomy who developed an air leak on the first postoperative day. The chest tubes were placed either on water seal or on 20 cm H2O continuous suction. No significant differences were found between the two groups in terms of duration of air leak (6.5 days vs. 6.3 days) and the incidence of prolonged air leak (27.8% vs. 30.1%). There was an almost significant increase in all postoperative complications, when water seal was compared to the suction group (31.9% vs. 17.8%, P=0.056). Obscurely, as a result of this study, the authors decided to institute a policy of 10 cm H2O suction at night and no suction in the day for their institution.
Ayed [3] in 2003 performed a randomised trial in Kuwait on 100 consecutive patients undergoing thoracoscopy for primary spontaneous pneumothorax. Patients were assigned into two groups to receive suction or water seal to their chest tubes after 2 h of suction. Fourteen percent of patients in the suction group had prolonged air leak compared to 2% of those in the water seal group. Also, the duration of chest tube days in-situ and hospital stay was lower in the water seal group (2.7 days) compared to the suction group (3.8 days). These results were found to be statistically significant.
Marshall et al. [4] in 2002 randomised 68 patients who underwent wedge resection, segmentectomy or lobectomy into a water seal group or suction group after return to the recovery room and a CXR while on suction. When corrected for staple lines, the duration of air leak (0.08 days vs. 0.17 days) and mean times to removal of chest tubes (0.17 days vs. 0.32 days) were significantly lower in the water seal group compared to the suction group. Hospital stay was also significantly shorter in the water seal group.
Cerfolio et al. [5–8] have published multiple papers addressing the issue of air leaks in thoracic patients, including the production of an algorithm and an air leak classification system. In their prospective randomised controlled trial, 33 patients who developed an air leak following pulmonary resection were assigned to either suction or water seal 48 h post surgery. Prolonged air leak (lasting more than 3 days) was found to be significantly reduced in the water seal only group with 12 of 18 stopping compared to only 1 out of 15 in the suction group. In addition, they described a 7-point air leak scale and in their study, all 6 persistent air leak patients had a score of 4 or more.
Antanavicius et al. [9] in 2005 retrospectively reviewed the duration of chest drains and hospital stay in 109 consecutive patients that underwent pulmonary procedures in their hospital in Pittsburgh, USA. Most patients with a post-operative air leak received suction but if no air leak was present, half of the patients tended to have no suction. (Decision was based entirely on surgeon's preference and was not randomised.) Chest tube and hospital stay duration were significantly lower in the no suction groups.
7. Conclusion
Of the six studies presented, no studies found in favour of suction to reduce the incidence of air leak, two studies found no difference between the two strategies, and four studies found evidence that water seal drainage without suction reduced the incidence of air leak. Five of the six studies used a short period of suction in the immediate post-operative period and the one study looking at immediate water seal drainage found no differences in outcome. Exceptions to the water seal strategy may be patients with a large air leak, or a large pneumothorax on CXR.
References
Alphonso N, Tan C, Utley M, Cameron R, Dussek J, Lang-Lazdunski L, Treasure T. A prospective randomised controlled trial of suction versus non-suction to the under-water seal drains following lung resection. Eur J Cardiothorac Surg 2005; 27:391–394.
Brunelli A, Monteverde M, Borri A, Salati M, Marasco RD, Al Refai M, Fianchini A. Comparison of water seal and suction after pulmonary lobectomy: a prospective, randomised trial. Ann Thorac Surg 1937; 77:1932–1937. discussion. p. 1937.
Ayed AK. Suction versus water seal after thoracoscopy for primary spontaneous pneumothorax: prospective randomised study. Ann Thorac Surg 2003; 75:1593–1596.
Marshall MB, Deeb ME, Bleier JI, Kucharczuk JC, Friedberg JS, Kaiser LR, Shrager JB. Suction versus water seal after pulmonary resection: a randomised prospective study. Chest 2002; 121:831–835.
Cerfolio RJ, Bass C, Katholi CR. Prospective randomised trial compares suction versus water seal for air leaks. Ann Thorac Surg 2001; 71:1613–1617.
Cerfolio RJ, Bryant AS, Singh S, Bass CS, Bartolucci AA. The management of chest tubes in patients with a pneumothorax and an air leak after pulmonary resection. Chest 2005; 128:816–820.
Cerfolio RJ. Recent advances in the treatment of air leaks. Curr Opin Pulm Medicine 2005; 11:319–323.
Cerfolio RJ, Tummala RP, Holman WL. A prospective algorithm for the management of air leaks after pulmonary resection. Ann Thorac Surg 1998; 66:1726–1731.
Antanavicius G, Lamb J, Papasavas P, Caushaj P. Initial chest tube management after pulmonary resection. Am Surgeon 2005; 71:416–419.(Aliu Sanni, Adam Critchle)