Management of Chest Tubes and Air Leaks after Lung Resection

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1 Management of Chest Tubes and Air Leaks after Lung Resection Emily Kluck PA-C The Johns Hopkins Hospital Baltimore, MD AATS 2014, Toronto, CAN April 2014

2 Management of Chest Tubes

3 1 Overview Review the indications for a chest tube Management techniques Recommendations for prolonged air leaks

4 Slide 3 1 Emily Kluck, 4/25/2014

5 History of the Chest Tube Hippocrates 460 B.C. Described the treatment of empyema by incision, drainage, and insertion of metal tubes Technique perfected during the Flu Epidemic of 1917 and then in World War II

6 Purpose of a Chest Tube (CT) Used to create negative pressure in chest cavity and allow re-expansion of the lung Helps drain air, blood, transudative, and exudative pleural effusions

7 Chest Tube Management Suction Actively suctions air and fluid from chest cavity Waterseal Clamp Trial

8 Chest Tube Management Suction Waterseal Passively allows fluid and air to escape chest cavity by gravity drainage Clamp Trial

9 Chest Tube Management Suction Waterseal Simulates the chest tube being removed from the patient to assess for a silent airleak Clamp Trial

10 Pleurovac Management Suction Control Chamber Collection Chamber Waterseal Chamber

11 Evolution of Pleurovac 3 Bottle System Analog Pleurovac Digital Pleurovac

12 Pleurovac Collection Chamber Allows fluid to be collected and allows for visualization of the fluid consistency

13 Pleurovac Collection Chamber CHECK DAILY! Assess for serous drainage, serousanginous, chyle, bile, gastric juices, pus!

14 Pleurovac Waterseal Chamber Acts as a one way valve allowing air to escape by gravity, but not to re-enter the chest cavity

15 Pleurovac Waterseal Chamber Airleak vs Normal Respiratory Variation vs No Tidaling

16 Pleurovac Suction Chamber Height of the water in this chamber regulates the negative pressure applied (10,20,30,40 cm of suction)

17 Chest Tube Management Algorithm Has yet to be scientifically determined or agreed upon by individual surgical groups Often physician specific based on training and anecdotal experience

18

19 Areas of Debate One versus two chest tubes AND POSITION!!!

20 Areas of Debate One versus two chest tubes Size of chest tube Pigtail Right Angle French

21 Areas of Debate One versus two chest tubes Size of chest tube Soft versus hard tubes Blake Tube Hard chest tube

22 Areas of Debate One versus two chest tubes Size of chest tube Soft versus hard tubes Water seal or suction

23 Areas of Debate One versus two chest tubes Size of chest tube Soft versus hard tubes Water seal or suction Drainage amount < 400ml/24 hr < 150 ml/24 hr

24 Areas of Debate One versus two chest tubes Size of chest tube Soft versus hard tubes Water seal or suction Drainage amount How to remove a chest tube Inspiration Expiration

25 Areas of Debate One versus two chest tubes Size of chest tube Soft versus hard tubes Water seal or suction Drainage amount Criteria for removal Daily CXR s

26 Chest Tube Management Based on Surgical Procedures Pleurodesis/D ecortication Requires hours suction to optimize visceral and parietal pleura with goal to obliterate space Suction Esophageal Surgery Placed near anastomosis in case of leak Waterseal Diaphragm Surgery Helps decrease fluid accumulation and obliterate space Suction

27 Common CT management Algorithm after Lung Resection Waterseal No increasing pneumothorax No subcutaneous emphysema Pleurodesis/Decortication Suction Increasing pneumothorax >1 cm postoperatively Increasing subcutaneous emphysema Difficult dissection or concern for bleeding

28 Postoperative CXR after Lung Resection Good Expansion >1 cm Pneumo Placed to Suction

29 Postoperative CXR after Lung Resection No Subcutaneous Emphysema Subcutaneous Emphysema Placed to Suction

30 What do you do when you have an AIRLEAK? What s the BIG DEAL?

31 Management of Airleaks Postoperatively Air leaks are the most common complication after lung resection which in turn increases hospital length of stay, and increases hospital cost

32 What is Respiratory Variation Respiratory Variation: Tidaling from negative pressure in chest cavity and considered Normal!

33 Respiratory Variation

34 Respiratory Variation Stormy Waters with NO bubbles

35 What is an Airleak Airleak: leakage of air across the alveolar surface of the visceral pleura (alveolar-visceral fistula)

36 Airleak Jacuzzi water with Bubbles

37 Description of Airleaks Continuous Intermittent With Cough When a new airleak is noted, the entire system and patients wound should be examined for an loose connections or slip in the tube

38 Management of Chest Tube with an Increasing pneumothorax Airleak Increasing subcutaneous emphysema Suction No increasing pneumothorax Waterseal No subcutaneous emphysema

39 Risk Factors for Prolonged Air Leak Steroid use Emphysematous lungs Re-operation with extensive scar tissue

40 Options for Prolonged Air Leak Heimlich Valve - One way valve that allows the patient to be discharged home with chest tube in place - Must tolerate waterseal - Weekly follow up visits to assess leak and determine when to remove chest tube

41 Options for Prolonged Air Leak Heimlich valve Blood patch - Autologous pleurodesis ml of blood taken from patient and injected into chest tube while patient is repositioned every 20 minutes for 1 hour

42 Options for Prolonged Air Leak Heimlich valve Blood patch Endobronchial valves - Currently on study trial - Placed in lobar or segmental bronchi - Permit air passage during expiration but not during inspiration

43 Options for Prolonged Air Leak Heimlich valve Blood patch Endobronchial valves Re-do operation - After failed attempts to maintain waterseal - Locate airleak and resect that portion of lung tissue - Biologic glue placed

44 When to Clamp a Chest Tube Goal: If a silent airleak is present, it will be revealed as increasing pneumothorax or subcutaneous emphysema on follow up CXR Airleak that has now resolved Difficult placement of chest tube/complicated patient/vip Patient still requiring positive pressure/ ventilator support

45 When to Pull a Chest Tube? When no air leak is present Output is serosanginous/ No sign of bleeding present Output < cc over a 24 hr Off positive pressure from ventilator

46 Thank you!

47 Management of the Postpneumonectomy Patient Emily Kluck PA-C The Johns Hopkins Hospital Baltimore, MD AATS 2014, Toronto, CAN April, 27, 2014

48 Overview Review the indications for a pneumonectomy Risk factors and complications associated with pneumonectomies Management strategies in patients with pneumonectomies

49 History of the Pneumonectomy First successful pneumonectomy was performed by Dr Graham in 1933 for lung cancer

50 Indications for Pneumonectomy Trauma Lung cancer Mesothelioma Lung Infection

51 Types of Pneumonectomies Standard Pneumonectomy Completion Pneumonectomy Extrapleural Pneumonectomy Removal of the affected lung and lymph nodes Removal of remaining lung after a prior lung resection Removal of the affected lung, resection of diaphragm, parietal pleura, and the pericardium

52 Types of Pneumonectomies Reconstructive Material

53 Pneumonectomy Complication Rate Carries higher morbidity and mortality compared to lobectomy and requires vigilant care by health care team Complication rates have been reported as high as 38%-59% Mortality rate is 3%-12%

54 Pneumonectomy Risks Factors Age > 65 Male sex Presence of congestive heart failure Preop FEV 1 less than 60% predicted Pneumonectomy for nonmalignant disease Extrapleural pneumonectomy Induction chemoradiation Right sided > left sided

55 Physiology Post Pneumonectomy Air reabsorbed and replaced by fluid

56 Physiology Post Pneumonectomy Air reabsorbed and replaced by fluid Shifting of the mediastinum toward the pneumonectomy side

57 Physiology Post Pneumonectomy Air reabsorbed and replaced by fluid Shifting of the mediastinum toward the pneumonectomy side Decrease in size of postpneumonectomy space

58 Physiology Post Pneumonectomy Air reabsorbed and replaced by fluid Shifting of the mediastinum toward the pneumonectomy side Decrease in size of postpneumonectomy space Elevation of the hemidiaphragm

59 Physiology Post Pneumonectomy Air reabsorbed and replaced by fluid Shifting of the mediastinum toward the pneumonectomy side Decrease in size of postpneumonectomy space Elevation of the hemidiaphragm Hyperinflation of the remaining lung

60 Physiology Post Pneumonectomy Day 2 Day 8 Day 30

61 Post-Pneumonectomy Immediate Postoperative Management Extubate if possible, take off positive pressure Minimize IV fluids to decrease fluid shifting Monitor for arrhythmias Pain management to decrease atelectasis

62 Purpose of a Chest Tube after Pneumonectomy Assess fluid consistency drainage from pleural space in the event there is unforeseen postoperative bleeding or air leak Equalizes the intrathoracic pressure of the chest cavity Allows slower shifting of the mediastinum

63 Purpose of a Chest Tube after Pneumonectomy Chest tubes should remain on waterseal or clamped Chest tube should NEVER be on suction! This would cause acute mediastinal shifting since there is no lung in that chest cavity to expand creating undesirable negative pressure

64 Pneumonectomy Complications Atrial fibrillation Bronchopleural fistula Post-pneumonectomy syndrome Prolonged intubation Empyema Aspiration Myocardial infarction Vocal cord paralysis Bleeding, patch dehiscence Respiratory distress syndrome

65 Atrial Fibrillation Remains the most common complication after thoracic surgery 10% to 20% after pulmonary lobectomy, and as much as 40-50% after pneumonectomy Occurs due to right heart strain, manipulation of the pericardium, and fluid/electrolyte shifts

66 Atrial Fibrillation After Pneumonectomy Calcium channel blockers and beta blockade are effective in reducing and regulating postoperative atrial fibrillation CCB/BB should be used prophylactically immediately postop if blood pressure stable Amiodarone beneficial but long term use shows increased risk of pulmonary fibrosis Magnesium and Potassium repleted

67 Post Pneumonectomy Syndrome Left Pneumonectomy Right Pneumonectomy

68 Post Pneumonectomy Syndrome Difficult Problem! PreOP PostOP Implant

69 Bronchopleural Fistula New decrease in air fluid level New cough with rusty colored blood Fever, new shortness of breath, chest pain POD 45 POD 60

70 Bronchopleural Fistula Excessive fluid can overflow into contralateral lung, causing aspiration pneumonia Patient should lie on their surgical side down

71 As much as life after the surgery is not normal, you can lead an ALMOST normal life with just ONE LUNG!

72 Q63. Do you take daily Chest Xrays on patients that have a chest tube in place? a. Yes b. No

73 Q64. Do you routinely pull chest tubes on: a. Inspiration b. Expiration c. Do not have specific pattern of pulling

74 Q65. Do you place a chest tube post pneumonectomy routinely to help monitor for bleeding or mediastinal shift? a. Yes b. No

75 Thank you!

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