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Ann Thorac Surg 2005;80:1052-1055
© 2005 The Society of Thoracic Surgeons
Unit of Thoracic Surgery, "Umberto I°" Regional Hospital, Ancona, Italy
Accepted for publication March 18, 2005.
* Address reprint requests to Dr Brunelli, Via S. Margherita 23, Ancona 60129, Italy (Email: alexit_2000{at}yahoo.com).
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Abstract |
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METHODS: Ninety-four patients with air leak on the morning of the first postoperative day were randomly assigned to two groups: group 1 (water seal alone), 47 patients; or group 2 (alternate suction), 47 patients. The groups were then compared in terms of preoperative, operative, and postoperative variables.
RESULTS: Alternate suction patients showed a reduced incidence of air leak longer than 4 days (p = 0.04) and longer than 7 days (p = 0.02), a shorter duration of chest tubes in place (p = 0.002), and a shorter postoperative hospital stay (p = 0.004).
CONCLUSIONS: Alternate suction was superior to water seal alone in reducing the incidence of prolonged air leak and postoperative hospital stay after lobectomy. As suction was applied only overnight, this modality has the same advantage of water seal in terms of early mobilization of patients.
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Introduction |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Therefore, the results of our previous study [4] prompted us to test a method of chest tube management that could combine the advantages of both water seal and suction (alternate suction: water seal during the day and suction overnight).
The objective of the present study is to compare this alternate suction method to water seal alone in a prospective randomized fashion and assess its influence on postoperative air leak after lobectomy.
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Patients and Methods |
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Patients underwent chest wall resection, and bronchoplastic procedures were excluded from the analysis. Resectability was evaluated by means of computed tomography (CT) scan, bronchoscopy, and when indicated, mediastinoscopy. Operability was assessed by means of arterial blood gas analysis, pulmonary function tests, electrocardiogram, echocardiography, and more invasive cardiologic tests if needed. A symptom-limited stair climbing test was systematically administered for risk stratification to all patients who were able to perform it. Operative exclusion criteria were a predicted postoperative forced expiratory volume in 1 second (ppoFEV1) less than 30% in association with a height lower than 12 m reached at the stair climbing test, and a hemodynamically unstable state.
All pulmonary lobectomies were performed at a single institution by one of four attending thoracic surgeons through a lateral muscle-sparing thoracotomy. Mechanical staplers were used to develop incomplete fissures in 85% of patients and to close the bronchus in all patients in the study. Approximately 15% of patients had completely developed or filmy fissures, which did not require the use of staplers. After completion of the lobectomy, a mediastinal lymphadenectomy was performed in all patients. After reinflation of the operated lung, air leaks were pinpointed by squirting sterile water over the lung and sutured. Upper lobectomies and bilobectomies underwent a pleural tent procedure, whenever possible (with the exception of extrapleural resection), according to the technique previously described [6].
Two 28F chest tubes were positioned before the closure of the thoracotomy, one anteriorly into the apex and one in a posterior-inferior position. During the immediate postoperative period, the chest tubes were placed on suction (–10 cmH2O) until the morning of the first postoperative day, at which time the patients without an air leak were excluded from the present analysis. Patients with an air leak present on the morning of the first postoperative day were randomly assign to one of two groups: group 1, in which the chest tubes were placed on water seal (24 hours a day); or group 2, in which the chest tubes remained on water seal during the day and then were converted to suction (–10 cm H2O) overnight. If an air leak persisted for more than 14 days, the chest tubes were connected to a Heimlich valve and the patients discharged unless otherwise contraindicated. Therefore, it was decided that the analysis had a maximum duration of 14 postoperative days, corresponding to the maximum duration of the alternate suction modality.
Simple unrestricted randomization was used to allocate patients in the two groups. No balancing techniques, such as minimization [5], were used.
Of the patients randomized in the two groups, 1 patient died and 2 patients required mechanical ventilation for more than 24 hours, and were, therefore, excluded from the analysis. Thus, a total of 94 patients (22 female, 72 male) with an air leak on postoperative day 1 formed the dataset of the present study (group 1, 24-hour water seal, 47 patients; group 2, alternate suction, 47 patients).
The following procedures were performed for each group: group 1, 15 right upper lobectomies, 12 left upper lobectomies, 8 left lower lobectomies, 6 right lower lobectomies, 4 right lower bilobectomies, 1 middle lobectomy, and 1 right upper bilobectomy; group 2, 14 right upper lobectomies, 10 left upper lobectomies, 9 left lower lobectomies, 8 right lower lobectomies, 3 right lower bilobectomies, 2 middle lobectomies, and 1 right upper bilobectomy.
The presence of an air leak was checked twice daily during morning and evening rounds. During the postoperative period, chest physiotherapy and incentive spirometry were administered to all patients, in addition to bronchodilators if needed. Chest tubes were removed when no air leak was evident (after a 24-hour clamping trial), and when the pleural effusion was less than 200 mL in 24 hours. Although not widely accepted, this chest tube removal policy is the current standard practice at our institution, and we chose to not modify it for the purpose of this study. For the purpose of this study, an air leak that persisted for more than 7 days was arbitrarily termed "prolonged." A quantitative analysis of air leak was not performed in this study.
We elected to not perform chest radiographs routinely and to obtain them only when clinically indicated (reduced breath sounds at auscultation, increased bronchial secretions, fever with leukocytosis, reduced oxygen saturation, a suspicion of chest tube malfunctioning, and so forth). This is a standard policy at our institution. Therefore, a systematic study on the occurrence of residual pleural spaces was not possible.
The following complications, occurring within 30 postoperative days (or over a longer period if the patients remained hospitalized), were considered for the analysis: atelectasis requiring bronchoscopy, pneumonia, pulmonary edema, adult respiratory distress syndrome, pulmonary embolism, pleural empyema, cardiac failure, arrhythmia requiring medical treatment, myocardial infarction, acute renal failure, and stroke.
Statistical Analysis
The sample size of this study was set to obtain a statistical power of 0.99 for detecting an expected difference of air leak duration of 2 days between the groups (according to other studies [2]) with a two-tailed significance level of 0.05. The numerical variables of the two groups were compared by means of the unpaired Student’s t test or the Mann-Whitney test. The 
2 test or Fisher’s exact test, when appropriate, was used to compare categorical variables.
The following preoperative variables were considered: the patient’s age and sex, forced expiratory volume in 1 second (FEV1), forced expiratory capacity (FVC), FEV1/FVC ratio, predicted postoperative FEV1 (ppoFEV1), residual volume to total lung capacity ratio (RV/TLC ratio), carbon monoxide diffusion lung capacity (DLCO), arterial oxygen tension (PaO2), arterial carbon dioxide level (PaCO2), preoperative hemoglobin and serum albumin concentrations, neoadjuvant chemotherapy, smoking history (pack-years), use of systemic steroids. The FEV1, FVC, ppoFEV1, and DLCO values were expressed as a percentage of predicted value for age, sex, and height. The ppoFEV1 was calculated on the basis of the functioning segments removed during operation and was estimated by CT scan and bronchoscopy [7]. If the calculated ppoFEV1 was less than 50% of the predicted value, a quantitative lung perfusion scan was performed [8]. The DLCO was measured by the single-breath method. We computed the number of pack-years of smoking as the total number of years smoked multiplied by the average number of cigarettes smoked per day, divided by 20.
Operative variables included the side (right and left) and site (upper and lower) of resection, the presence of pleural adhesions, and the length of the stapled parenchyma (mm). For the purpose of this study, the following procedures were classified as upper resections: right and left upper lobectomies, right upper bilobectomy and middle lobectomy. Lower resections included right and left lower lobectomies, and right lower bilobectomy. Only dense pleural adhesions occupying more than 30% of a lobe or more than one lobe were taken into consideration for the analysis.
Postoperative variables included the duration of air leak in days, the presence of a prolonged air leak (PAL), the duration of chest tube use in days, the quantity of pleural effusion during the first postoperative 48 hours, the presence of other complications, and the length of postoperative hospital stay in days.
All tests were two-tailed, with a significance level of 0.05, and were performed on the statistical software Statview 5.0 (SAS, Cary, North Carolina).
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Results |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Pleural tents were performed in 16 patients of group 1 and in 14 of group 2 (p = 0.7). Four patients with pleural tent in group 1 had a prolonged air leak (longer than 7 days) versus no patient in group 2 (p = 0.1 by Fisher’s exact test). Five patients without pleural tent in group 1 had a prolonged air leak versus 2 patients in group 2 (p = 0.2 by Fisher’s exact test).
There was no difference in cardiopulmonary complications between the groups. Five patients in group 1 and 4 in group 2 had pulmonary complications (p = 1 by Fisher’s exact test). Eight patients in group 1 and 7 in group 2 had cardiac complications (p = 1 by Fisher’s exact test). Arrhythmia developed in 5 patients in group 1 and in 7 patients in group 2 (p = 0.8 by Fisher’s exact test). Pneumonia developed in 4 patients in group 1 and in 1 patient in group 2 (p = 0.4 by Fisher’s exact test). Atelectasis developed in 1 patient in the water seal group versus 4 patients in the alternate suction group (p = 0.4 by Fisher’s exact test).
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Comment |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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This study was prompted by the results of our previous analysis [4] that showed that water seal was not superior to continuous suction in reducing air leak after lobectomy. Nevertheless, in that study, we showed that water seal was safe and well tolerated by the patients, as reported also by others [1, 2, 5]. Moreover, water seal allows patients to ambulate early and more freely. An alternate moderate (–10 cmH2O) suction has the theoretical advantages of favoring the apposition of parietal and visceral pleurae, promoting the sealing of air leaks during the night, and allowing free mobilization of the patients during the day.
In this study, the alternate suction method reduced the number of prolonged air leaks, the chest tube days, and the postoperative hospital stay, compared with water seal alone after pulmonary lobectomy. Even the mean air leak duration was shorter in the alternate suction group, even though the study was not powered enough to ascertain significance for a mean difference of 1 day. Only 17% of the patients in the alternate suction group experienced an air leak lasting more than 4 days compared with 36% of the patients in the water seal group. This demonstrates that adding a moderate suction (–10 cmH2O) to water seal for a limited period of time (12 hours) improves the course of air leaks, without compromising the mobilization of the patients.
A comparison of our results with those of previous studies [1–5] assessing the postoperative chest tube management is difficult, as none of these studies tested an alternate suction method. We think the encouraging findings of this study warrant a larger multi-institutional prospective trial to confirm the efficacy of this modality of chest tube management.
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References |
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This article has been cited by other articles:
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  A. Brunelli, F. Xiume, M. Al Refai, M. Salati, R. Marasco, and A. Sabbatini Air leaks after lobectomy increase the risk of empyema but not of cardiopulmonary complications: a case-matched analysis. Chest, October 1, 2006; 130(4): 1150 - 1156. [Abstract] [Full Text] [PDF]
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 M. B. Marshall Invited commentary Ann. Thorac. Surg., September 1, 2005; 80(3): 1055 - 1055. [Full Text] [PDF]
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