Should a chest tube be placed on suction or water seal?

From the Guidelines

I recommend connecting the chest tube to water seal rather than suction in this situation, as the most recent and highest quality study suggests that drainage of symptomatic pneumothorax with an underwater seal is the current standard of care 1. For most newly placed chest tubes, especially those treating pneumothorax, the management depends on clinical circumstances.

• The British Thoracic Society guideline for pleural disease recommends drainage of symptomatic pneumothorax with an underwater seal as the current standard of care 1.
• The American College of Chest Physicians Delphi consensus statement suggests that attachment of the chest tube to a water seal device with or without suction is acceptable management for most patients 1.
• The management of closed system drainage should include a unidirectional flow drainage system, such as an underwater seal bottle, which must be kept below the level of the patient’s chest at all times 1. To implement this, connect the chest tube to a commercial drainage system, ensure all connections are secure, and fill the water seal chamber to the appropriate level.
• Monitor for bubbling in the water seal chamber (indicating air leak), drainage output, and patient symptoms.
• Transition to suction can be considered if the lung fails to reexpand or if there is a large air leak. The rationale for initial water seal is that it provides a safe and effective way to manage pneumothorax, and suction can be added if necessary to facilitate pleural space evacuation and promote lung re-expansion.
• The use of suction should be guided by clinical judgment and the patient's individual needs, rather than being applied routinely to all patients with chest tubes 1.

From the Research

Chest Tube Management

The decision to place a chest tube on suction or water seal depends on various factors, including the patient's condition and the underlying cause of the chest tube insertion.

• The use of suction or water seal is guided by the patient's specific needs, such as the presence of an air leak or the size of the pneumothorax 2.
• A study published in 2018 found that suction seems to have a positive effect on duration of chest tube treatment, length of stay in hospital, and persistent air leakage in chest trauma 3.
• However, another study published in 2005 suggested that keeping chest tubes on water seal is safe for most patients with an air leak and a pneumothorax, but may not be suitable for patients with large air leaks or pneumothoraces 2.
• The optimal management of chest tubes also depends on the type of surgery performed, with some procedures requiring active suction and others benefiting from water seal 4.

Indications for Suction or Water Seal

The indications for suction or water seal are not clearly established, but some studies suggest that:

• Suction may be beneficial for patients with persistent air leaks or large pneumothoraces 2, 3.
• Water seal may be suitable for patients with small air leaks or pneumothoraces, but may not be effective for patients with large air leaks or pneumothoraces 2.
• The use of suction or water seal should be guided by the patient's individual needs and the underlying cause of the chest tube insertion 5, 6.

Complications and Considerations

The management of chest tubes is not without complications, and considerations should be taken to minimize the risk of:

• Infection, subcutaneous emphysema, pain, and re-expansion pulmonary edema 5, 6.
• The optimal timing for tube removal is still a matter of controversy, but digital drainage systems may facilitate informed decision-making 5.
• The use of novel digital drainage systems may reduce interobserver variability in air leak assessment and shorten chest tube duration and overall hospital stay 4.