Is chest tube placement to suction necessary in the presence of a pneumothorax (collapsed lung) with an air leak?

From the Guidelines

You should not apply suction to a chest tube immediately after insertion in the case of an air leak, but rather consider adding it after 48 hours for persistent air leak or failure of the pneumothorax to re-expand, as recommended by the BTS guidelines 1. When managing a patient with an air leak, it's essential to consider the potential risks and benefits of applying suction to a chest tube. The BTS guidelines suggest that suction should not be applied directly after tube insertion, but rather after 48 hours for persistent air leak or failure of the pneumothorax to re-expand 1. Some key points to consider when deciding whether to apply suction to a chest tube include:

• The size of the pneumothorax and the presence of any underlying lung disease
• The presence of a persistent air leak, which is usually arbitrarily defined as a continued air bubbling through an intercostal tube 48 hours after insertion
• The need for specialist medical and nursing experience in managing patients requiring suction
• The potential risks of applying suction too early, including re-expansion pulmonary oedema (RPO) In terms of the specifics of suction application, the guidelines recommend using high volume, low pressure (–10 to –20 cm H2O) suction systems, such as a Vernon-Thompson pump or wall suction with an adaptor to reduce pressure 1. It's also important to note that the patient should be situated in an area where specialist nursing experience is available if suction is to be applied to a chest drain 1. Overall, the decision to apply suction to a chest tube in the case of an air leak should be made on a case-by-case basis, taking into account the individual patient's needs and circumstances, and guided by the most recent and highest quality evidence available, which in this case is the BTS guidelines 1.

From the Research

Chest Tube Management for Air Leaks

• The decision to place a chest tube to suction in the presence of an air leak depends on various factors, including the size of the air leak and the patient's underlying condition 2, 3.
• Small-bore chest tubes (≤14F) are generally recommended as the first-line therapy for spontaneous pneumothorax in non-ventilated patients, while large-bore chest drains may be useful for very large air leaks 2.
• Chest tube insertion should be guided by imaging, and the tube should be connected to a drainage system device, such as a flutter valve, underwater seal, or electronic system 2.
• The use of suction may be necessary in some cases, but it is not routinely recommended unless gravity drainage is not effective 2.
• Persistent air leaks (>2 days' duration) can be managed with interventional pulmonology techniques, such as bronchoscopic sealing of air leaks, which can avoid the requirement for thoracic surgical intervention 3.
• The optimal timing for tube removal is still a matter of controversy, but the use of digital drainage systems can facilitate informed decision-making 2.