Management of Chest Tubes and

Air Leaks after Lung Resection

Emily Kluck PA-C

The Johns Hopkins Hospital
Baltimore, MD
AATS 2014, Toronto, CAN
April 2014

Management of Chest Tubes

Overview
Review the indications for a chest
tube
Management techniques
Recommendations for prolonged
air leaks

Slide 3
1

Emily Kluck, 4/25/2014

History of the Chest Tube

Hippocrates 460 B.C.
Described the
treatment of empyema
by incision, drainage,
and insertion of metal
tubes

Technique perfected during

the Flu Epidemic of 1917 and
then in World War II

Purpose of a Chest Tube (CT)

Used to create negative
pressure in chest cavity
and allow re-expansion
of the lung
Helps drain air, blood,
transudative, and exudative pleural
effusions

Chest Tube Management

Suction
Waterseal
Clamp Trial

Actively suctions air and

fluid from chest cavity

Chest Tube Management

Suction
Waterseal
Clamp Trial

Passively allows fluid and

air to escape chest cavity
by gravity drainage

Chest Tube Management

Suction
Waterseal
Clamp Trial

Simulates the chest tube

being removed from the
patient to assess for a
silent airleak

Pleurovac Management

Suction Control
Chamber

Waterseal Chamber

Collection
Chamber

Evolution of Pleurovac

3 Bottle
System

Analog
Pleurovac

Digital
Pleurovac

Pleurovac
Collection Chamber
Allows fluid to be
collected and allows for
visualization of the fluid
consistency

Pleurovac
Collection Chamber
CHECK DAILY!

Assess for serous drainage,

serousanginous, chyle, bile,
gastric juices, pus!

Pleurovac
Waterseal Chamber
Acts as a one way valve
allowing air to escape by
gravity, but not to re-enter
the chest cavity

Pleurovac
Waterseal Chamber
Airleak vs Normal Respiratory
Variation vs No Tidaling

Pleurovac
Suction Chamber
Height of the water in this
chamber regulates the
negative pressure applied
(10,20,30,40 cm of suction)

Chest Tube Management Algorithm

Has yet to be scientifically determined or
agreed upon by individual surgical groups
Often physician specific based on training
and anecdotal experience

Areas of Debate
One versus two chest tubes

AND POSITION!!!

Areas of Debate
One versus two chest tubes
Pigtail
Size of chest tube

Right Angle

16-36 French

Areas of Debate
One versus two chest tubes
Size of chest tube
Soft versus hard tubes
Blake Tube

Hard chest tube

Areas of Debate

One versus two chest tubes

Size of chest tube
Soft versus hard tubes
Water seal or suction

Areas of Debate

One versus two chest tubes

Size of chest tube
Soft versus hard tubes
Water seal or suction
Drainage amount
< 400ml/24 hr
< 150 ml/24 hr

Areas of Debate

One versus two chest tubes

Size of chest tube
Soft versus hard tubes
Water seal or suction
Drainage amount
How to remove a chest tube

Inspiration

Expiration

Areas of Debate

One versus two chest tubes

Size of chest tube
Soft versus hard tubes
Water seal or suction
Drainage amount
Criteria for removal
Daily CXRs

Chest Tube Management Based on

Surgical Procedures
Pleurodesis/D
ecortication
Esophageal
Surgery
Diaphragm
Surgery

Requires 24-72 hours suction to

optimize visceral and parietal pleura
with goal to obliterate space

Placed near
anastomosis in
case of leak

Suction

Waterseal

Helps decrease fluid

accumulation and
obliterate space

Suction

Common CT management Algorithm

after Lung Resection
No increasing pneumothorax

Waterseal
No subcutaneous emphysema
Pleurodesis/Decortication

Suction

Increasing pneumothorax >1 cm

postoperatively
Increasing subcutaneous emphysema
Difficult dissection or concern for bleeding

Postoperative CXR after Lung

Resection
Good Expansion

>1 cm Pneumo

Placed to Suction

Postoperative CXR after Lung

Resection
No Subcutaneous Emphysema

Subcutaneous Emphysema

Placed to Suction

What do you do when you have

an AIRLEAK?

Whats the BIG DEAL?

Management of Airleaks
Postoperatively
Air leaks are the most common complication after
lung resection which in turn increases hospital
length of stay, and increases hospital cost

What is Respiratory Variation

Respiratory Variation: Tidaling from negative
pressure in chest cavity and considered Normal!

Respiratory Variation

Respiratory
Variation Stormy
Waters with NO
bubbles

What is an Airleak
Airleak: leakage of air
across the alveolar
surface of the visceral
pleura (alveolar-visceral
fistula)

Airleak
Jacuzzi water with Bubbles

Description of Airleaks
Continuous
Intermittent
With Cough
When a new airleak is noted, the entire system and patients
wound should be examined for an loose connections or slip in
the tube

Management of Chest Tube with an

Airleak
Increasing pneumothorax
Increasing subcutaneous
emphysema

Suction

No increasing pneumothorax

Waterseal
No subcutaneous emphysema

Risk Factors for Prolonged Air Leak

Steroid use
Emphysematous
lungs
Re-operation with
extensive scar tissue

Options for Prolonged Air Leak

Heimlich Valve

- One way valve that allows the

patient to be discharged home with
chest tube in place
- Must tolerate waterseal
- Weekly follow up visits to assess
leak and determine when to remove
chest tube

Options for Prolonged Air Leak

Heimlich valve
Blood patch

- Autologous pleurodesis
- 80-120 ml of blood taken from
patient and injected into chest tube
while patient is repositioned every
20 minutes for 1 hour

Options for Prolonged Air Leak

Heimlich valve
Blood patch
Endobronchial
valves

- Currently on study trial

- Placed in lobar or segmental
bronchi
- Permit air passage during
expiration but not during
inspiration

Options for Prolonged Air Leak

Heimlich valve
Blood patch
Endobronchial
valves
Re-do operation

- After failed attempts to maintain

waterseal
- Locate airleak and resect that
portion of lung tissue
- Biologic glue placed

When to Clamp a Chest Tube

Goal: If a silent airleak is present, it will be
revealed as increasing pneumothorax or
subcutaneous emphysema on follow up CXR
Airleak that has now resolved
Difficult placement of chest tube/complicated
patient/VIP
Patient still requiring positive pressure/
ventilator support

When to Pull a Chest

Tube?
When no air leak is present
Output is serosanginous/ No sign of
bleeding present
Output < 150-400 cc over a 24 hr
Off positive pressure from ventilator

Thank you!

Management of the
Postpneumonectomy Patient

Emily Kluck PA-C

The Johns Hopkins Hospital
Baltimore, MD
AATS 2014, Toronto, CAN
April, 27, 2014

Overview
Review the indications for a
pneumonectomy
Risk factors and complications
associated with pneumonectomies
Management strategies in patients with
pneumonectomies

History of the Pneumonectomy

First successful pneumonectomy

was performed by Dr Graham in
1933 for lung cancer

Indications for Pneumonectomy

Trauma
Lung cancer
Mesothelioma
Lung Infection

Types of Pneumonectomies
Standard
Completion
Pneumonectomy Pneumonectomy
Removal of the
affected lung and
lymph nodes

Removal of
remaining lung after
a prior lung
resection

Extrapleural
Pneumonectomy
Removal of the
affected lung, resection
of diaphragm, parietal
pleura, and the
pericardium

Types of Pneumonectomies
Reconstructive
Material

Pneumonectomy Complication Rate

Carries higher morbidity and mortality
compared to lobectomy and requires vigilant
care by health care team
Complication rates have been reported as high
as 38%-59%
Mortality rate is 3%-12%

Pneumonectomy Risks Factors

Age > 65
Male sex
Presence of congestive heart failure
Preop FEV 1 less than 60% predicted
Pneumonectomy for nonmalignant disease
Extrapleural pneumonectomy
Induction chemoradiation
Right sided > left sided

Physiology Post Pneumonectomy

Air reabsorbed and
replaced by fluid

Physiology Post Pneumonectomy

Air reabsorbed and
replaced by fluid
Shifting of the
mediastinum toward the
pneumonectomy side

Physiology Post Pneumonectomy

Air reabsorbed and
replaced by fluid
Shifting of the
mediastinum toward the
pneumonectomy side
Decrease in size of postpneumonectomy space

Physiology Post Pneumonectomy

Air reabsorbed and replaced
by fluid
Shifting of the mediastinum
toward the pneumonectomy
side
Decrease in size of postpneumonectomy space
Elevation of the
hemidiaphragm

Physiology Post Pneumonectomy

Air reabsorbed and replaced
by fluid
Shifting of the mediastinum
toward the pneumonectomy
side
Decrease in size of postpneumonectomy space
Elevation of the
hemidiaphragm
Hyperinflation of the
remaining lung

Physiology Post Pneumonectomy

Day 2

Day 8

Day 30

Post-Pneumonectomy
Immediate Postoperative Management
Extubate if possible, take off positive
pressure
Minimize IV fluids to decrease fluid
shifting
Monitor for arrhythmias
Pain management to decrease atelectasis

Purpose of a Chest Tube after

Pneumonectomy
Assess fluid consistency drainage from pleural space
in the event there is unforeseen postoperative bleeding
or air leak
Equalizes the intrathoracic pressure of the chest
cavity
Allows slower shifting of the mediastinum

Purpose of a Chest Tube after

Pneumonectomy
Chest tubes should remain on waterseal or
clamped
Chest tube should NEVER be on suction!
This would cause acute mediastinal shifting
since there is no lung in that chest cavity to
expand creating undesirable negative pressure

Pneumonectomy Complications
Atrial fibrillation
Bronchopleural fistula
Post-pneumonectomy
syndrome
Prolonged intubation
Empyema

Aspiration
Myocardial infarction
Vocal cord paralysis
Bleeding, patch
dehiscence
Respiratory distress
syndrome

Atrial Fibrillation
Remains the most common complication after
thoracic surgery
10% to 20% after pulmonary lobectomy, and as
much as 40-50% after pneumonectomy
Occurs due to right heart strain, manipulation of
the pericardium, and fluid/electrolyte shifts

Atrial Fibrillation After

Pneumonectomy
Calcium channel blockers and beta blockade
are effective in reducing and regulating
postoperative atrial fibrillation
CCB/BB should be used prophylactically
immediately postop if blood pressure stable
Amiodarone beneficial but long term use shows
increased risk of pulmonary fibrosis
Magnesium and Potassium repleted

Post Pneumonectomy Syndrome

Left Pneumonectomy

Right Pneumonectomy

Post Pneumonectomy Syndrome

Difficult Problem!
PreOP

PostOP

Implant

Bronchopleural Fistula
New decrease in air fluid level
New cough with rusty colored blood
Fever, new shortness of breath, chest pain

POD 45

POD 60

Bronchopleural Fistula
Excessive fluid can overflow into contralateral
lung, causing aspiration pneumonia
Patient should lie on their surgical side down

As much as life after the surgery is not normal,

you can lead an ALMOST normal life with just

ONE LUNG!

Q63.DoyoutakedailyChestXrayson
patientsthathaveachesttubeinplace?
a. Yes
b. No

Q64.Doyouroutinelypullchesttubeson:
a. Inspiration
b. Expiration
c. Donothavespecificpatternofpulling

Q65.Doyouplaceachesttubepost
pneumonectomyroutinelytohelpmonitor
forbleedingormediastinalshift?
a. Yes
b. No

Thank you!