From the Guidelines
The decision to use chest tube to suction versus water seal should be based on the patient's clinical status and the presence of a persistent air leak, with suction typically applied after 48 hours if the pneumothorax fails to re-expand or if there is a persistent air leak, as recommended by the BTS guidelines 1.
Clinical Indications for Suction vs Water Seal
- Suction is recommended for patients with a persistent air leak or failure of the pneumothorax to re-expand after 48 hours, with a high volume, low pressure system (-10 to -20 cm H2O) being the preferred method 1.
- Water seal is appropriate for patients without a persistent air leak and with minimal drainage, serving as a trial before chest tube removal to assess lung expansion without active suction.
- Certain situations, such as large persistent air leaks, incomplete lung expansion, or ongoing significant drainage, require continued suction.
Recommendations for Chest Tube Management
- The American College of Chest Physicians Delphi consensus statement recommends using a water seal device without suction initially for clinically unstable patients with large pneumothoraces, with suction applied if the lung fails to re-expand with water seal drainage 1.
- However, the more recent 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 a pneumothorax to re-expand, taking precedence due to its more recent publication and specific focus on spontaneous pneumothorax management 1.
Key Considerations for Patient Care
- Patients requiring suction should be managed in an area with specialist medical and nursing experience, as recommended by the BTS guidelines 1.
- The water seal trial should last 4-24 hours, during which the patient should be monitored for respiratory distress, oxygen desaturation, or pneumothorax recurrence.
- If the patient remains stable with a fully expanded lung on chest X-ray during water seal, the chest tube can typically be removed, optimizing lung healing while minimizing complications and hospital length of stay.
From the Research
Decision Making for Chest Tube Management
The decision to use suction or water seal for chest tube management depends on various factors, including the size of the air leak and the presence of a pneumothorax.
- Studies have shown that water seal is superior to wall suction for stopping most air leaks after pulmonary resection 2, 3, 4.
- However, if a patient has a large air leak (greater than an expiratory 3 on the classification system) or experiences subcutaneous emphysema or an expanding pneumothorax that causes hypoxia, some suction (-10 cm of water) should be applied to the chest tubes 2, 3.
- Air leaks that are 4/7 or greater on the leak meter are less likely to resolve with water seal alone and may require suction 4.
- The management of chest tubes after pulmonary resection can be tailored to individual patient needs, with most patients able to have their tubes removed by postoperative day 3 5.
Factors Influencing Chest Tube Management
Several factors can influence the decision to use suction or water seal, including:
- Size of the air leak: larger air leaks may require suction 2, 3, 4.
- Presence of a pneumothorax: patients with a pneumothorax and an air leak may require suction if the pneumothorax is large or symptomatic 3.
- Development of subcutaneous emphysema or an expanding pneumothorax: these complications may require suction 2, 3.
- Patient symptoms and overall clinical condition: patient symptoms and clinical condition should be taken into account when deciding on chest tube management 5.