Q. Is it necessary to clamp a chest tube prior to d/c the chest tube? What is best practice to go from suction to water seal, then clamp and d/c or suction to water seal and then d/c? Can you give me any contact information on references for best practice on clamping chest tubes prior to discontinuation? Thank you.Theresa Austin, MSN-L ,RN RN Clinical Education Specialist- Pediatric Service line Cardon Children’s Medical Center at Banner Desert Medical Center
A. To clamp or not to clamp? That is the question. I was not able to find any research that compared clamping with no clamping. For this response, I am thinking about patients with pleural tubes who are not receiving mechanical ventilation; I’d never clamp a tube if a patient were receiving positive pressure. As for other non-critical patients (typically postoperative) If I were writing the orders, I would prefer to have pleural tubes clamped the night before anticipated removal, and if the patient did fine, pull the tube on morning rounds. The argument in favor of clamping is that if the patient gets breathless or shows other signs of recurring pneumothorax, it is much easier to simply open the clamp rather than face the risk of pulling the tube too soon and having to replace it. I think clamping to simulate removal in order to assess the patient is hard to argue with, but is not evidence-based. Otherwise, I would not clamp a tube — even to change out a chest drain. I’d be concerned that I might get called from the bedside for an emergency and not open the clamp; it’s the same reason I don’t turn off monitor alarms – I just silence them.
As for the literature, a frequently referenced approach, called “provocative clamping,” is described in a letter to the editor of Annals of Thoracic Surgery as one way to manage patients with prolonged air leak.1 It’s provocative because it involves clamping a tube in a patient with a known leak from the surface of the lung. But one of the best resources is a letter to the editor of Chest in which a writer is in favor of clamping and provides 8 references to support his position. In response, the author of the original article responds with 5 references that support not clamping the tube2. (available online here with links to available full text references)
There has been some good evidence on suction versus gravity drainage after lung surgery. University of Pennsylvania researchers reported their experience randomizing postoperative pulmonary resection patients (not including LVRS) into two groups. One group’s chest drains remained connected to the vacuum regulator with the suction control chamber set for a level of –20 cmH2O; the others were disconnected from the wall vacuum and remained on gravity drainage with the water seal of the chest drain.3 Sixty-eight patients who underwent pulmonary wedge resection were included with 34 in each arm of the study. The two groups were evenly matched; 15 patients in each group had an air leak at the end of the operation. All patients were connected to wall vacuum in the operating room to re-expand the lung at the end of the case. Vacuum was disconnected for transport to the PACU. There, patients were randomized to resume vacuum or to stay on gravity water seal drainage – two days earlier than in a previous study4. If a pneumothorax >25% was present on a chest radiograph in the gravity drainage group, the chest drain was reconnected to wall vacuum with a suction level of –10 cmH2O until the pneumothorax was <10%. (Note that none of the patients was symptomatic.) Then, gravity drainage was reestablished. Patients on the wall vacuum protocol had suction control chambers set to –20 cmH2O.
Patients with air leaks in the gravity water seal drainage group had a mean leak duration of 1.50 days. In the wall vacuum group, mean leak duration was 3.27 days. Chest tubes in the gravity water seal patients remained in place a mean of 3.33 days; in the wall vacuum group, the mean duration was 5.47 days. Even when taking the length of staple lines into account, the differences between the two groups remained. The researchers found that the duration of air leaks in the gravity water seal group was about one-half the time of the wall vacuum group. Since many argue that suction is critical to apposition of the pleurae postoperatively, these researchers initially used suction on all patients in the operating room. These researchers note that visually, the bubbling is more vigorous in the water seal chamber when the chest drain is connected to wall vacuum, indicating a greater flow of air out of the lung. They suggest that the benefit of reducing airflow, thereby allowing the suture line to be more closely approximated, aids healing and outweighs any benefit of pleural apposition.
The researchers conclude that placing patients on gravity water seal drainage helps resolve air leaks after pulmonary surgery more quickly than when suction is used. They state that routinely using wall vacuum postoperatively is counterproductive.
Overall, the literature supports using gravity drainage and significantly limiting or avoiding use of suction altogether unless there is a specific indication for suction based on a careful patient assessment5-12. Based on these findings, I would go to water seal as soon as possible and remove the tube from there. There is no need to clamp the tube unless you wish to simulate chest tube removal to determine patient tolerance.
1. Kirschner PA: “Provocative clamping” and removal of chest tubes despite persistent air leak. Annals of Thoracic Surgery 1992;53(4):740-741.
2. Gupta N: Pneumothorax : Is Chest Tube Clamp Necessary Before Removal? Chest 2001;119(4):1292-1293.
3. Marshall MB, Deeb ME, Bleier JI, et al: Suction vs water seal after pulmonary resection: a randomized prospective study. Chest 2002;121(3):831-835.
4. Cerfolio RJ, Bass C, Katholi CR: Prospective randomized trial compares suction versus water seal for air leaks. Annals of Thoracic Surgery 2001;71(5):1613-1617.
5. Merritt RE, Singhal S, Shrager JB. Evidence-based suggestions for management of air leaks. Thorac Surg Clin. Aug 2010;20(3):435-448.
6. Cerfolio RJ, Bryant AS: The management of chest tubes after pulmonary resection. Thoracic Surgery Clinics 2010;20(3):399-405.
7. Cerfolio RJ, Bryant AS, Singh S, Bass CS, Bartolucci AA: The management of chest tubes in patients with a pneumothorax and an air leak after pulmonary resection. Chest 2005;128(2):816-820.
8. Powner DJ, Cline CD, Rodman GH: Effect of chest-tube suction on gas flow through a bronchopleural fistula. Critical Care Medicine 1985;13(2):99-101.
9. Alphonso N, Tan C, Utley M, et al: A prospective randomized controlled trial of suction versus non-suction to the under-water seal drains following lung resection. European Journal of Cardiothorac Surgery 2005;27(3):391-394.
10. Prokakis C, Koletsis EN, Apostolakis E, et al: Routine suction of intercostal drains is not necessary after lobectomy: a prospective randomized trial. World Journal of Surgery 2008;32(11):2336-2342.
11. Deng B, Tan Q, Zhao Y, Wang R, Jiang Y: Suction or non-suction to the underwater seal drains following pulmonary operation: meta-analysis of randomised controlled trials. European Journal of Cardio-Thoracic Surgery 2010;38:210-215.
12. Ayed AK: Suction versus water seal after thoracoscopy for primary spontaneous pneumothorax: prospective randomized study. Annals of Thoracic Surgery 2003;75(5):1593-1596.