What is the evidence for using suction with chest drain for spontaneous pneumothorax?

From the Guidelines

The use of suction with chest drains in spontaneous pneumothorax should be limited to patients with persistent air leaks or failure of lung re-expansion after 48 hours, with suction applied at -10 to -20 cm H2O, as recommended by the most recent guidelines 1. Initial management should involve chest tube insertion with water seal drainage alone, without suction, as this is sufficient for most patients. The evidence from recent studies does not support the routine use of suction with chest drains in spontaneous pneumothorax, and instead suggests that it may be beneficial as a second-line approach in specific cases 1. Some key points to consider when deciding whether to apply suction include:

• The presence of a persistent air leak after 48 hours
• Failure of the lung to re-expand
• The size of the pneumothorax and the presence of underlying lung disease
• The risk of complications such as re-expansion pulmonary edema The decision to apply suction should be individualized based on clinical response to initial water seal drainage, with close monitoring for complications. High volume, low pressure suction systems are recommended, such as a Vernon-Thompson pump or wall suction with an adaptor to reduce pressure, as they are less likely to cause air stealing, hypoxaemia, or perpetuation of persistent air leaks 1. It is also important to note that patients requiring suction should only be managed on lung units where there is specialist medical and nursing experience 1.

From the Research

Evidence for Suction with Chest Drain in Spontaneous Pneumothorax

• The use of suction with a chest drain in spontaneous pneumothorax has been studied in several research papers 2, 3, 4, 5, 6.
• A study published in 2006 found that wall suction was applied if the lung failed to re-expand after 24-48 hours of using a one-way Heimlich valve, with a 24-hour success rate of 61% and a 1-week success rate of 85% 2.
• Another study published in 2012 found that the overall success rate of using a small-bore chest drain with a Heimlich valve was 65.5%, with a surgical pleurodesis rate of 23.6% 3.
• A 2009 study found that the use of a small-bore catheter connected to a one-way Heimlich valve was effective in the outpatient management of primary spontaneous pneumothorax, with a success rate of 81% and a complication rate of 22.6% 4.
• An early study published in 1973 used a Heimlich flutter valve to achieve intrapleural evacuation of air in 16 patients with spontaneous pneumothorax, resulting in complete lung expansion in 17 (94.4%) of the episodes by five days 5.
• A systematic review published in 2011 found 17 systematic reviews, RCTs, or observational studies that met the inclusion criteria, including information on the effectiveness and safety of chest-tube drainage (alone or plus suction) and other interventions 6.

Key Findings

• The use of suction with a chest drain can be an effective treatment for spontaneous pneumothorax, with success rates ranging from 61% to 85% 2, 3, 4.
• The application of wall suction after initial use of a one-way Heimlich valve can improve lung re-expansion rates 2.
• Small-bore chest drains with a Heimlich valve can be a safe and efficacious mode of treatment for primary spontaneous pneumothorax, enabling management of the majority of patients as outpatients 3, 4.