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© 2003 European Association of Cardio-Thoracic Surgery
Implementation of a user-friendly protocol for interpretation of air-leaks and management of intercostal chest drains after thoracic surgeryThe Price-Thomas Thoracic Surgical Unit, Northern General Hospital, Herries Road, Sheffield S5 7AU, UK
* Corresponding author. Tel.: +44-114-271-4950; fax: +44-114-271-4289 Received October 25, 2002; received in revised form January 21, 2003; accepted February 27, 2003
We prospectively audited the implementation of a protocol for management of air-leaks and intercostal drains after thoracic surgical procedures. Out of the 99 patients who underwent thoracic surgical procedures during a 3-month period, 41 presented a postoperative air-leak on day 1. The protocol was strictly followed in 95% of the cases. The median drainage-time and hospital-stay were 3 and 4 days, respectively. The incidence of insertion of postoperative drains was 3%. Most of the nursing staff found the protocol user-friendly and easy to apply. A protocol for the management of postoperative air-leaks and intercostal drains can be implemented with high-compliance low complications.
Key Words: Chest drains; Clinical pathway
Postoperative air-leaks are common after thoracic surgery. Reports have estimated their incidence ranging from 25 to 75% depending on the type of procedures performed [1–3]. Air-leaks after surgery can determine morbidity and hospital stay, with the increase in the use of resources [4–6]. In the literature, methods to classify air-leaks according to the phase of the respiratory cycle have been described [7]. In thoracic surgery, protocols of care and clinical pathways have been reported to reduce hospital stay and treatment costs [8,9]. We implemented a protocol to classify air-leaks according to their likely origin and their severity and to select a mode of treatment according to the type of air-leak.
Following the introduction of the protocol by the senior author (G.R.), we audited the implementation of the guidelines in terms of compliance and clinical outcomes. We selected different end-points to evaluate our experience: overall incidence of postoperative air-leaks, incidence of prolonged air-leaks (PAL, greater than 7 days), length of intercostal drainage period, length of postoperative stay, compliance with the protocol, need to reinsertion of additional chest drains after surgery, and protocol user-friendliness by the ward nursing staff. The protocol (Fig. 1) includes a list of recommendations based of the different types of air-leaks identified daily during the ward-rounds. The intercostal drains were removed when no air-leak was seen, the lung was fully expanded in the chest radiograph, and the total drainage over a 24-h period did not exceed 250 ml. In the cases when more than one intercostal drain was inserted at operation, the drainage time was calculated when the last drain was removed.
2.1. Definitions of air-leak Four types of postoperative air-leaks were identified:
2.2. Surgical methods All the procedures were performed under general anaesthesia with isolated lung ventilation. In cases of pulmonary resection, biological sealants and techniques to reduce the thoracic cavity size were used freely according to individual preferences. All patients, with the exception of pneumonectomies and patients undergoing lung volume reduction surgery, are placed on a negative low-suction circuit of 2.5kPa immediately after surgery that was maintained during the first postoperative night.2.3. Patients This prospective study includes the 99 consecutive patients who underwent thoracic surgical procedures that required intercostal drainage during a 3-month period (February–May 2002). The procedures were performed under the care of two dedicated thoracic surgeons in our unit. There were 62 males and 37 females with a median age of 60 (range 20–78) years. The median FEV1 was 70% of the predicted (range 18–119%). In 66 cases, the operations involved lung resection and the remaining 33 included a variety of thoracic operations requiring intercostal drainage but without performing lung resection. The different procedures are listed in Table 1.
2.4. Data presentation and analysis The data is presented in median and range unless specifically stated. Qualitative data was analysed using the Chi square and Fisher's exact tests. Comparison between quantitative variables was made with the Mann–Whitney test for non-parametric data. Results were considered significant if P value <0.05.
Among the 99 patients included in the study, there was one postoperative death (1%). A patient who underwent right upper lobectomy for a stage Ib adenocarcinoma suffered a fatal myocardial infarction on day 9 post-surgery. Fifty-one patients (52%) had one chest drain, 44 (44%) had two chest drains, and three drains were inserted in four patients (4%) who underwent decortication for empyema. A total of ten patients (10.1%) required intensive care unit admission either electively (seven cases) or due to complications (three cases), with a median stay of 1 (range 1–8) day. 3.1. Postoperative air-leaks An air-leak on postoperative day 1 was encountered in 41 patients (41%). There were no cases of active bronchial leaks. In three patients, severe broncho-alveolar leaks were identified on day 1 and the remainder 38 patients presented passive air-leaks. The incidence of an air-leak was 48% after pulmonary resection that was higher than 27% after procedures without lung resection . Other factors such as age or evidence of pulmonary obstructive disease on spirometry did not significantly increase the incidence of postoperative air-leak ( in all cases). During the period of drainage, flutter-valve drainage system was employed in 34 patients (34.3%), provocative chest drain clamping prior to removal in four patients, and talc pleurodesis was performed in two patients.
The mean drainage time was 3 (range 1–17) days and was measured when the final drain was removed in patients with more than one intercostal drain Fig. 2. The mean drainage time in the group of 58 patients with no air-leak after surgery was 2 (range 1–6) days, significantly lower than the median of 3 (range 1–17) days in the group of 41 patients that presented an air-leak in the morning after surgery
Seven patients presented a PAL lasting more than 7 days (7%). Only two patients were discharged with a chest drain in-situ attached to a flutter valve bag. 3.2. Length of hospital stay The median postoperative hospital stay was 4 days (range 1–52). Patients who did not present a postoperative air-leak were discharged significantly earlier (median of 3 days, range 1–11 days) than patients with an air-leak (median of 5 days, range 2–52) . Patients who underwent lung resection stayed longer in hospital than those who did not, but the difference was not found to be significant  . Only 11 patients (11%) stayed in hospital more than 8 days after surgery (Fig. 3).
3.3. Compliance with protocol and failure rate The decisions made regarding the management of intercostal drains and air-leaks were found to comply with the protocol recommendations in 94 patients (95%). At least one decision was found not to comply with the protocol guidelines in the remaining five patients. In two of these cases, the involved patients refused to follow the clinician's advice and requested their drains to be removed in circumstances that did not fulfil the protocol's recommendations. Failure rate, as expressed by the number of additional intercostal drains re-inserted following surgery, was 3% (three cases). In all of them, the indication was a residual intra-thoracic space. The primary operations were lobectomy, bilateral uniportal video-assisted thoracic surgery (VATS) sympathectomy, and a VATS pleurectomy for recurrent pneumothorax. In all three cases, no further treatment was needed and were discharged home without other complications. A small residual apical space was identified in the chest radiograph following removal of the intercostal drains in five additional cases (5%). None of them required active intervention and did resolve by the following days' radiograph. There were no cases of significant postoperative pleural effusion in our experience. 3.4. Staff questionnaire Forty-one out of the 45 anonymous questionnaires sent to nursing staff involved in the care with thoracic surgical patients were returned. In 36 cases (88%), the involved staff thought that the protocol was clear to understand and deemed it as user-friendly. In only three cases (7%), the staff questioned the protocol as difficult to understand. The two remaining members of the nursing staff felt they were too new to the protocol to evaluate it adequately.
Postoperative air-leaks after thoracic surgery are common and can influence morbidity and postoperative hospital stay. Nevertheless, decisions regarding management of air-leaks and intercostal drains depend largely on individual experiences. Few algorithms for the management of air-leaks after pulmonary resection have been described in the literature and there is still a debate in identifying the ideal method to reduce their incidence [1,10,11]. Recently, Cerfolio et al. [1] have attempted to classify different types of air-leaks according to the phase of the respiratory cycle where the leak was present: continuous, expiratory, inspiratory, and forced expiratory. In the same manuscript, a quantitative classification was reported in an attempt to predict PAL [1]. We have elected to classify air-leaks, according to their likely origin, as bronchial, broncho-alveolar, and passive. This classification will allow us to determine the best treatment option and to compare outcomes in similar ‘stage’ air-leaks. We provide a series of recommendations according to the type of air-leak and chest X-ray appearances. These recommendations were based on available evidence and personal surgeons' experiences. The incidence of air-leaks on the first day after thoracic surgery is reported only in the few manuscripts designed to specifically assess air-leaks. One of the lowest incidence reported after pulmonary resection, a 26% air-leak rate on day 1, may be the result of suture reinforcement of the stapled lines in all cases [1]. Other authors have reported rates of up to 74% [2]. In our series, the incidence of postoperative day 1 air-leaks of 48% after pulmonary resection and 41% after any thoracic surgical procedure that required intercostal drainage lies within the standards reported in the literature [3]. Our results also compared with the literature in the absence or low incidence of what we defined as active air-leaks [1]. A common problem reported after thoracic surgery is the presence of PAL traditionally defined as leaks present over 7 days after surgery. PAL can delay discharge by 5–13 days [4,5]. The incidence of PAL also varies with procedures and different units ranging from 5% in the series by Cerfolio et al. [12], 15% in the series of the Cleveland Clinic [5], to over 25% after right upper lobectomy [6]. Our results of a 7% incidence of PAL greater than 7 days compares favourably with most of the available data. Another of our outcomes measures refers to the median drainage time of 3 days observed in our series. In different studies with similar outcome measures, the times are considerably longer, reaching up to 6 days consistently [13,14]. The high compliance to the protocol by the involved practitioners and the answers to the questionnaires by the nursing staff indicated to us that the protocol was clear and user-friendly, and the low failure rate of 3% chest drain reinsertion confirmed the safety of the protocol for patient's outcomes. It is difficult to find in the literature reports the need for chest drain reinsertion. Rice et al. described the need for insertion of an additional intercostal drain in 4.5% of cases after pulmonary resection [5]. The incidence of small, non-significant apical spaces after removal of chest drain is not unusual with reports of 15% after lobectomy/bilobectomy with pleural tenting [15] to 20% after lung resection/decortication [16]. In summary, we believe that we have implemented a protocol for the management of air-leaks and intercostal chest drains after thoracic surgery that is easy to follow and user-friendly. It has also proven to be safe for patients with a low incidence of local complications. Once we have got a basic knowledge of our current practice with our guidelines, we are preparing further studies in an attempt to more adequately ‘stage’ air-leaks and to compare different methods of treatment for the air-leaks, aiming to reduce drainage times, and length of hospital stay after thoracic surgical procedures.
ICVTS on-line discussion Author: Praveen Varma, Cardiovascular and Thoracic Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum 695011, India Date: 9-Apr-2003 03:45 Message: Interesting article on air leak after thoracic surgery. The authors have evolved a protocol for management of air leaks. We do around 200 thoracic procedures per year. Our protocol is to have 2 chest drains one apical and the other basal for all cases requiring resections (except pneumonectomy where only one tube is placed). Both tubes are placed in low suction. The apical tube is removed only after the air leaks have stopped and basal when drainage is minimal. The air leaks are more with the kind of disease, with tuberculous lung and bronchiectasis which requires more days of drainage. This is because of air leaks from parenchyma due to adhesiolysis. With this protocol we hardly had to put any additional tubes.
Presented at the 10th Annual Meeting of the European Society of Thoracic Surgeons, Istanbul, Turkey, October 26–28, 2002. doi:10.1016/S1569-9293(03)00054-9
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Abstract
1. Introduction
. The drainage time did not differ significantly between the 66 patients undergoing lung resection and the 33 who did not 
. 
