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
Management of Chest Tubes
1 Overview Review the indications for a chest tube Management techniques Recommendations for prolonged air leaks
Slide 3 1 Emily Kluck, 4/25/2014
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
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
Chest Tube Management Suction Actively suctions air and fluid from chest cavity Waterseal Clamp Trial
Chest Tube Management Suction Waterseal Passively allows fluid and air to escape chest cavity by gravity drainage Clamp Trial
Chest Tube Management Suction Waterseal Simulates the chest tube being removed from the patient to assess for a silent airleak Clamp Trial
Pleurovac Management Suction Control Chamber Collection Chamber Waterseal Chamber
Evolution of Pleurovac 3 Bottle System Analog Pleurovac Digital Pleurovac
Pleurovac Collection Chamber Allows fluid to be collected and allows for visualization of the fluid consistency
Pleurovac Collection Chamber CHECK DAILY! Assess for serous drainage, serousanginous, chyle, bile, gastric juices, pus!
Pleurovac Waterseal Chamber Acts as a one way valve allowing air to escape by gravity, but not to re-enter the chest cavity
Pleurovac Waterseal Chamber Airleak vs Normal Respiratory Variation vs No Tidaling
Pleurovac Suction Chamber Height of the water in this chamber regulates the negative pressure applied (10,20,30,40 cm of suction)
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
Areas of Debate One versus two chest tubes AND POSITION!!!
Areas of Debate One versus two chest tubes Size of chest tube Pigtail Right Angle 16-36 French
Areas of Debate One versus two chest tubes Size of chest tube Soft versus hard tubes Blake Tube Hard chest tube
Areas of Debate One versus two chest tubes Size of chest tube Soft versus hard tubes Water seal or suction
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
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
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
Chest Tube Management Based on Surgical Procedures Pleurodesis/D ecortication Requires 24-72 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
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
Postoperative CXR after Lung Resection Good Expansion >1 cm Pneumo Placed to Suction
Postoperative CXR after Lung Resection No Subcutaneous Emphysema Subcutaneous Emphysema Placed to Suction
What do you do when you have an AIRLEAK? What s the BIG DEAL?
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
What is Respiratory Variation Respiratory Variation: Tidaling from negative pressure in chest cavity and considered Normal!
Respiratory Variation
Respiratory Variation Stormy Waters with NO bubbles
What is an Airleak Airleak: leakage of air across the alveolar surface of the visceral pleura (alveolar-visceral fistula)
Airleak Jacuzzi water with Bubbles
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
Management of Chest Tube with an Increasing pneumothorax Airleak Increasing subcutaneous emphysema Suction No increasing pneumothorax Waterseal No subcutaneous emphysema
Risk Factors for Prolonged Air Leak Steroid use Emphysematous lungs Re-operation with extensive scar tissue
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
Options for Prolonged Air Leak Heimlich valve Blood patch - Autologous pleurodesis - 80-120 ml of blood taken from patient and injected into chest tube while patient is repositioned every 20 minutes for 1 hour
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
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
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
When to Pull a Chest Tube? When no air leak is present Output is serosanginous/ No sign of bleeding present Output < 150-400 cc over a 24 hr Off positive pressure from ventilator
Thank you!
Management of the Postpneumonectomy Patient Emily Kluck PA-C The Johns Hopkins Hospital Baltimore, MD AATS 2014, Toronto, CAN April, 27, 2014
Overview Review the indications for a pneumonectomy Risk factors and complications associated with pneumonectomies Management strategies in patients with pneumonectomies
History of the Pneumonectomy First successful pneumonectomy was performed by Dr Graham in 1933 for lung cancer
Indications for Pneumonectomy Trauma Lung cancer Mesothelioma Lung Infection
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
Types of Pneumonectomies Reconstructive Material
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%
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
Physiology Post Pneumonectomy Air reabsorbed and replaced by fluid
Physiology Post Pneumonectomy Air reabsorbed and replaced by fluid Shifting of the mediastinum toward the pneumonectomy side
Physiology Post Pneumonectomy Air reabsorbed and replaced by fluid Shifting of the mediastinum toward the pneumonectomy side Decrease in size of postpneumonectomy space
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
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
Physiology Post Pneumonectomy Day 2 Day 8 Day 30
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
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
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
Pneumonectomy Complications Atrial fibrillation Bronchopleural fistula Post-pneumonectomy syndrome Prolonged intubation Empyema Aspiration Myocardial infarction Vocal cord paralysis Bleeding, patch dehiscence Respiratory distress syndrome
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
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
Post Pneumonectomy Syndrome Left Pneumonectomy Right Pneumonectomy
Post Pneumonectomy Syndrome Difficult Problem! PreOP PostOP Implant
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
Bronchopleural Fistula Excessive fluid can overflow into contralateral lung, causing aspiration pneumonia Patient should lie on their surgical side down
As much as life after the surgery is not normal, you can lead an ALMOST normal life with just ONE LUNG!
Q63. Do you take daily Chest Xrays on patients that have a chest tube in place? a. Yes b. No
Q64. Do you routinely pull chest tubes on: a. Inspiration b. Expiration c. Do not have specific pattern of pulling
Q65. Do you place a chest tube post pneumonectomy routinely to help monitor for bleeding or mediastinal shift? a. Yes b. No
Thank you!