BIRMINGHAM, ALA—Are chest tubes plus wall suction best for managing air leaks? Or is the combination of chest tubes and water seal preferable? The controversy has finally been settled—at least for patients who have undergone pulmonary surgery. In a recent clinical trial, water seal was found to be considerably better at stopping air leaks after pulmonary resection.[1] In fact, suction “usually only made air leaks bigger,” lead investigator Robert J. Cerfolio, MD, said in an interview with PULMONARY REVIEWS.

These findings could spark a widespread switch to water seal, which is not as widely used as wall suction, said Dr. Cerfolio, Associate Professor of Surgery at the University of Alabama at Birmingham. Despite its popularity, suction often prolongs hospitalization because it prevents air leaks from sealing and may increase the size of some leaks, Dr. Cerfolio stressed.

FIRST SCIENTIFIC STUDY

Although air leaks are the main complications of pulmonary surgery, Dr. Cerfolio and colleagues were the first to study their management scientifically. They looked at 140 consecutive patients (ages 3 to 83 years) who had elective pulmonary resection. A mass or nodules in the lung were the most common reason for surgery.

All patients with chest tubes were given suctioning (at 20 cm H2O) until the second postoperative day. They were then prospectively randomized to water seal or to continued suction. Those in the water-seal group were switched to suction only if a pneumothorax developed. To gauge the leaks, the researchers developed a classification system for air leaks, which scored them based on their type and size. To assess the leaks’ size, they used a commercially available meter to measure the leaks from smallest to largest on a 1-to-7 scale.

EFFECTIVE, BUT NOT FOR EVERYONE

Eighteen patients in the water-seal group and 15 in the suction group had an air leak on the second postoperative day. These leaks resolved by the morning of the third day in 12 (67%) of the patients who had a water seal but in only one (7%) of those receiving suction—a highly significant difference.

The 14 patients in whom suction failed were switched to water seal; this stopped the air leaks in all but one patient by the fourth day. Thus, water seal worked in 25 of 32 patients, for a 78% overall success rate.

All six of the patients given water seal who still had air leaks on the third post-operative day had large leaks (a score of 4 or higher). In five of these patients, pneumothorax developed, and they were switched to suction.

Of the 25 patients in whom water seal was effective, all but one had had a leak score of 3 or lower on the first postoperative day. Similarly, of the patients whose leaks resolved before the sixth day, all had had a score of 4 or lower initially. Conversely, six of the seven patients who still had an air leak on the sixth day had had a score of 5 or higher on the first postoperative day.

Because of his findings, Dr. Cerfolio recommends water seal for most patients with an air leak; the exceptions are those with a very large leak. “Low levels of suction, such as –10 cm H2O, are required in that subgroup,” he concluded.

—Timothy Begany

Reference
1. Cerfolio RJ, Bass C, Katholi CR. Prospective randomized trial compares suction versus water seal for air leaks. Ann Thorac Surg. 2001;71:1613-1617.

Return to table of contents