Original article: general thoracic
Prospective randomized trial compares suction versus water seal for air leaks

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Abstract

Background. Surgeons treat air leaks differently. Our goal was to evaluate whether it is better to place chest tubes on suction or water seal for stopping air leaks after pulmonary surgery. A second goal was to evaluate a new classification system for air leaks that we developed.

Methods. Patients were prospectively randomized before surgery to receive suction or water seal to their chest tubes on postoperative day (POD) #2. Air leaks were described and quantified daily by a classification system and a leak meter. The air-leak meter scored leaks from 1 (least) to 7 (greatest). The group randomized to water seal stayed on water seal unless a pneumothorax developed.

Results. On POD #2, 33 of 140 patients had an air leak. Eighteen patients had been preoperatively randomized to water seal and 15 to suction. Air leaks resolved in 12 (67%) of the water seal patients by the morning of POD #3. All 6 patients whose air leak did not stop had a leak that was 4/7 or greater (p < 0.0001) on the leak meter. Of the 15 patients randomized to suction, only 1 patient’s air leak (7%) resolved by the morning of POD #3. The randomization aspect of the trial was ended and statistical analysis showed water seal was superior (p = 0.001). The remaining 14 patients were then placed to water seal and by the morning of POD #4, 13 patients’ leaks had stopped. Of the 32 total patients placed to seal, 7 (22%) developed a pneumothorax and 6 of these 7 patients had leaks that were 4/7 or greater (p = 0.001).

Conclusions. Placing chest tubes on water seal seems superior to wall suction for stopping air leaks after pulmonary resection. However, water seal does not stop expiratory leaks that are 4/7 or greater. Pneumothorax may occur when chest tubes are placed on seal with leaks this large.

Section snippets

Patients and methods

Between August 1, 1997 and June 1, 1998, 140 consecutive patients underwent elective pulmonary resection by a single surgeon (R.J.C.) at The University of Alabama at Birmingham. Exclusion criteria included any patient who had pulmonary resection performed exclusively by video-assisted thoracoscopy, had lung volume reduction surgery, pneumonectomy or any type of broncho-plastic procedure (i.e., sleeve resection). No patients refused entry into this trial secondary due to its safe design.

Standard

Suction versus water seal

The median age at the time of pulmonary resection in these 140 patients (96 men, 44 women) was 54 years (range 3 years to 83 years). Forty-one patients had a previous history of cardiac disease (either coronary artery bypass surgery, balloon angioplasty, or exertional angina), 28 had insulin-dependent diabetes mellitus, 13 had chronic renal failure (on dialysis), 7 had a previous ipsilateral thoracotomy, and 6 were on chronic steroids (at least 20 mg of prednisone per day). Twelve patients had

Comment

The decision to place chest tubes on suction versus water seal for many surgeons is based more on when, where, and how he or she trained as opposed to any scientific data. Because of this fact, we have performed several studies on air leaks and developed a classification system. This is an attempt to bring science to this common problem. Our previous trial [1] showed that water seal was safe for patients with air leaks. It enabled us to perform this prospective randomized trial with both IRB

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