What to do if a patient still has an air leak after water sealing a chest tube (chest drainage tube)?

Management of Persistent Air Leak After Water Sealing Chest Tube

For patients with persistent air leak after water sealing a chest tube, apply high volume, low pressure suction (-10 to -20 cm H2O) after 48 hours, and refer to a thoracic surgeon within 3-5 days if the air leak persists. 1

Initial Assessment and Management

When a patient continues to have an air leak after water sealing a chest tube:

1. Confirm true air leak:

   • Ensure the bubbling is not due to reverse airflow during deep inspiration, which can mimic a true air leak 2
   • Check for bubbling during expiration, which indicates a genuine air leak

2. Apply appropriate suction:

   • Do not apply suction immediately after tube insertion
   • Wait 48 hours before applying suction to persistent air leaks 3, 1
   • Use high volume, low pressure suction systems (-10 to -20 cm H2O) 3
   • Avoid high pressure systems that can generate excessive air flow and potentially perpetuate air leaks 3

3. Consider water seal trial:

   • For small air leaks, water seal (passive suction) may be more effective than active suction 4, 5
   • In one study, 67% of air leaks resolved within 24 hours of switching to water seal, compared to only 7% with continued suction 4

Timing of Specialist Referral

• Refer to a respiratory specialist if the air leak exceeds 48 hours 3, 1
• Seek thoracic surgical opinion within 3-5 days for persistent air leak or failure of lung re-expansion 3, 1
• Consider earlier surgical referral (2-4 days) for patients with:
  • Underlying lung disease
  • Large persistent air leak
  • Failure of lung re-expansion 3

Management Based on Patient Factors

For patients without underlying lung disease:

• Apply suction after 48 hours if air leak persists
• Refer for surgical evaluation at 5-7 days if leak continues 3

For patients with underlying lung disease:

• Apply suction after 48 hours if air leak persists
• Consider earlier surgical referral (2-4 days) 3
• Be aware that resolution may take longer (median 19 days vs 8 days for those without lung disease) 3

Surgical and Chemical Options

1. Surgical intervention (preferred approach):

   • Video-assisted thoracoscopic surgery (VATS) with staple bullectomy and pleural symphysis
   • Open thoracotomy and pleurectomy for difficult or recurrent pneumothoraces 3, 1

2. Chemical pleurodesis:

   • Consider only if the patient is unwilling or unable to undergo surgery 3
   • Should be performed by a respiratory specialist 3
   • Doxycycline or talc slurry are preferred agents 1

Common Pitfalls and Caveats

1. Tube management issues:

   • Check for malpositioned, kinked, or blocked tubes 1
   • Ensure appropriate tube size (larger tubes may be necessary for very large air leaks) 1
   • Never clamp a bubbling chest tube 1

2. Suction-related issues:

   • Applying suction too early after tube insertion can precipitate re-expansion pulmonary oedema 3
   • High pressure suction can lead to air stealing, hypoxemia, or perpetuation of persistent air leaks 3

3. Pneumothorax with water seal:

   • About 22% of patients placed on water seal may develop a pneumothorax 4
   • This risk is higher with larger air leaks (≥4/7 on leak measurement scales) 4
   • If pneumothorax develops or subcutaneous emphysema worsens, resume suction 5

4. Outpatient management:

   • Most patients with persistent air leaks can be safely discharged home on an outpatient device
   • Tubes can typically be removed in 2-3 weeks even with ongoing air leak 5

By following this structured approach to persistent air leaks, you can optimize patient outcomes while minimizing complications and unnecessary prolongation of chest tube drainage.