When to apply negative suction for a non-expanding pneumothorax managed with an intercostal drainage (ICD) approach?

Negative Suction for Non-Expanding Pneumothorax with Intercostal Drainage

Negative suction should be applied to an intercostal drain when a pneumothorax fails to resolve with simple underwater seal drainage alone, particularly when there is persistent lung collapse despite adequate chest tube placement and patency. 1

Initial Management of Pneumothorax

• For initial management of pneumothorax requiring intervention:
  • Small-bore chest tubes (≤14F) are recommended as first-line treatment
  • Initially connect to underwater seal without suction
  • Confirm tube position with chest radiograph immediately after insertion

When to Apply Negative Suction

Apply negative suction in the following scenarios:

1. Persistent pneumothorax despite adequate drainage

   • When chest radiograph shows continued lung collapse after 24-48 hours with underwater seal alone
   • When there is clinical deterioration or respiratory compromise

2. Large air leaks

   • When significant bubbling is present in the underwater seal
   • When the lung fails to re-expand despite adequate drainage

3. Complete lung collapse

   • For primary spontaneous pneumothorax with complete lung collapse, intercostal drainage with suction may be more effective than simple drainage alone 2
   • Research shows significantly better immediate success with intercostal drainage compared to needle aspiration in complete lung collapse (62% vs 11%) 2

Suction Parameters and Technique

• Apply negative pressure of -15 to -20 cm H2O 3
• Use a regulated suction system to maintain consistent pressure
• Digital thoracic suction systems (like Thopaz) may be beneficial for persistent pneumothoraces 4
• Monitor for:
  • Lung re-expansion on chest radiograph
  • Resolution of air leak
  • Clinical improvement

Important Considerations and Pitfalls

1. Avoid excessive suction

   • Higher negative pressures can worsen air leaks
   • May cause trauma to lung parenchyma

2. Persistent air leaks

   • If air leak persists with suction, consider temporarily discontinuing suction
   • Evidence suggests that discontinuing suction resolved persistent air leaks in some cases 3

3. Drainage system positioning

   • Always keep the drainage system below chest level
   • Never clamp a bubbling chest tube due to risk of tension pneumothorax 1

4. Duration of suction

   • Continue suction until lung re-expansion is confirmed on chest radiograph
   • Once the air leak resolves and lung expands, transition to underwater seal without suction before removal

Special Considerations

• Secondary pneumothorax: Patients with underlying lung disease may benefit more from suction, particularly those with interstitial lung disease 4

• Surgical candidates: For persistent non-expanding pneumothorax despite suction for >3-5 days, consider surgical referral for definitive management 1

• Portable digital suction systems: Consider for patients requiring prolonged suction, as they allow for mobilization and potential outpatient management 4

Evidence Quality Assessment

The available evidence on suction versus no suction for pneumothorax shows mixed results:

• A randomized study found no significant advantage of suction over simple underwater seal drainage in terms of success rates (57% vs 50%) or hospital stay 5

• However, more recent evidence suggests that suction can be beneficial in specific scenarios such as complete lung collapse 2 or persistent pneumothorax with underlying lung disease 4

• The British Thoracic Society guidelines recommend initial management without suction, with suction reserved for non-expanding pneumothoraces 1