ICVTS Click here for other ICVTS advertising opportunities
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Interact CardioVasc Thorac Surg 2008;7:1155-1159. doi:10.1510/icvts.2008.181750
© 2008 European Association of Cardio-Thoracic Surgery
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Sandro Mattioli
Richard G. Berrisford
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Google Scholar
Right arrow Articles by Mattioli, S.
Right arrow Articles by Aramini, B.
PubMed
Right arrow PubMed Citation
Right arrow Articles by Mattioli, S.
Right arrow Articles by Aramini, B.
Related Collections
Right arrowRelated Article

Brief communication - Thoracic general

Survey on chest drainage systems adopted in Europe{star}

Sandro Mattiolia,*, Richard G. Berrisfordb, Maria Luisa Lugaresia and Beatrice Araminia

a Division of Oesophageal and Pulmonary Surgery, University of Bologna, Villa Maria Cecilia e San Pier Damiano Hospitals, Cotignola and Faenza (Ravenna), Italy
b Royal Devon & Exeter NHS Foundation Trust, Barrack Road, Exeter EX2 5DW, UK

Received 11 April 2008; received in revised form 4 August 2008; accepted 5 August 2008

{star} This study was supported by a grant from EUROSETS SRL Medical Device, Medolla, Modena, Italy.

Corresponding author. Università degli Studi di Bologna – Dipartimento di Chirurgia Generale e dei Trapianti d'Organo- Via Massarenti 9 – 40138 Bologna, Italy. Tel.: +39 051 6364870; fax: +39 051 347431.

E-mail address: sandro.mattioli{at}unibo.it (S. Mattioli).


   Abstract
Top
 Abstract
1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
 References
 
The aim of this survey, promoted by the European Society of Thoracic Surgeons, was to acquire information and advice from ‘the field’ in order to promote development of technology for thoracic surgery and to provide information for future guidelines on chest drainage. Society members were offered a questionnaire on the European Society of Thoracic Surgeons website (November 2006) composed of seven sections comprehending 21 detailed items. The questionnaire was completed by 120 centres, 100% performed lung surgery, 91.6% mediastinal surgery, 54.1% oesophageal surgery, 10% cardiothoracic surgery. The PVC straight drain (mean 55.9%) and silicon drain (mean 38.4%), water-valve/water suction disposable chest drainage collection system (mean 43.4%), one bottle (mean 24.8%), and two bottles with suction control (mean 18.2%), were the most frequently used. After pneumonectomy 51.2% used a balanced drainage system, 9% periodical thoracocentesis, 39.8% others. In 57.5–92% drainage suction was stopped ≤4 postoperative days and in 8–42.5% >4 postoperative days. In 17.6–60.7% drains were removed ≤4 postoperative days and in 39.3–82.4% >4 postoperative days. The survey demonstrates a trend toward the use of updated technical devices, high consideration of the costs, and clinical practice based on personal preferences.

Key Words: Thoracic surgery; Chest drainage systems; Chest; Lung; Mediastinum; Oesophagus


   1. Introduction
Top
 Abstract
 1. Introduction
2. Material and methods
 3. Results
 4. Discussion
 References
 
The aim of this survey, organised by the European Society of Thoracic Surgeons (ESTS), was to document a review of current chest drainage practice by the members of the Society, to inform further technological development of drainage systems and provide information for future guidelines.


   2. Material and methods
Top
 Abstract
 1. Introduction
 2. Material and methods
3. Results
 4. Discussion
 References
 
Members of ESTS were informed of the survey by email. The questionnaire was accessed via a secure hyperlink from the ESTS home page (http://www.ests.org) from November 2006.

The questionnaire comprised seven Sections: Section 1, Centres. Section 2, Thoracic drains. Section 3, Chest drainage collection systems (CDCS). Section 4, Chest drainage collection system details. Section 5, Drainage after pneumonectomy. Section 6, Ambulatory drainage and suction. Section 7, Global evaluation of CDCS, duration of chest drainage suction, timing of drain removal.

2.1. Statistical analysis

The {chi}2 test or the Fisher exact test were used. Statistical analyses were performed using SPSS 12.00 software package (SPSS Inc, Chicago, IL).


   3. Results
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
4. Discussion
 References
 
The questionnaire was completed by 120 divisions or units of Thoracic or Cardio-Thoracic Surgery (Fig. 1). The European centres are listed in the Appendix. Responses collected are summarised below.


Figure 1
View larger version (57K):
[in this window]
[in a new window]

  		Fig. 1. Geographic distribution of centres participating to ESTS Survey.

 
3.1. Section 1

All participating surgeons performed lung surgery (100%), 91.6% mediastinal surgery, 54.1% oesophageal surgery, 10% cardiac surgery.

3.2. Section 2

The PVC straight drain (mean 55.9%, range 53.9–60.2%) and Silicon drain (mean 38.4%, range 35.5–41.7%) were the most frequently used (preferred drain types for pulmonary vs. oesophageal surgery P<0.05).

3.3. Section 3

Water valve/water suction disposable CDCS (mean 43.4%, range 35–50%), one bottle (mean 24.8%, range 15.8–29.2%) and two bottles with suction control (mean 18.2%, range 11.7–22.5%) were the most frequently used.

3.4. Section 4

3.4.1. Single/multiple chambers
The 60.1% of respondents never used a disposable dual fluid collection chamber. 12.7% preferred to separate two drains from the same hemithorax, 9.3% drained the right and left chest separately and 15.2% both.

3.4.2. Pressure relief valves
There was equivalence with regard to automaticity of the ‘high negative pressure’ relief valve in a disposable CDCS, 52.6% manual activation and 47.3% automatic.

3.4.3. Sterilising membrane
The incorporation of a sterilising membrane between the fluid collection chamber and water seal was felt to be essential by 20%, useful by 51.3% and useless by 28.7%.

3.4.4. Tubing clamp system
Fewer respondents felt that a sequential tube clamp system for temporarily closing aspiration was essential (13%). 57.9% felt it useful and 28.9% unnecessary.

3.4.5. Air leak monitoring
The 46.4% felt that either CDCS or the one bottle/two bottle system was best; 29.8% preferred the one bottle/two bottle system and 23.6% preferred the CDCS.

3.4.6. Suction
The 87.8% preferred five suction settings (0, –10, –20, –30, –40 cm H2O) compared with two (0, -20 cm H2O) (6.9%) or three (0, –20 and –40 cm H2O) suction settings (5.2%, P=0.004).

The majority of surgeons (77.7%) indicated that a CDCS which automatically set the level of suction according to the air-leak rate was useful.

3.4.7. Tipping over
Tipping over of the CDCS appears to be a frequent problem with 70.2% recording frequent tipping over although some surgeons (29.8%) reported that this never happens.

3.5. Section 5

The most popular protocol used (51.2%) was a pneumonectomy balanced drainage system.

3.6. Section 6

In the presence of a persistent (3–7 days) or prolonged (>7 days) air leak, the most popular management (37.8%) was to mobilize the patient with a chest drain valve.

In the presence of a minor (<3 days) air leak, the majority (42.8%) mobilized the patient with a standard CDCS and operated suction when the patient is at the bedside.

3.7. Section 7

3.7.1. Worst feature of currently used system
The worst features most often quoted were the risk complications relating to drain breakage (20%) and the difficulty of employing bottle systems (17.3%).

3.7.2. Best feature of currently used system
The best feature most often quoted (49%) was simplicity of management by nursing and trainee medical staff, simplicity and control of costs (12%).

3.7.3. Time to stop suction
The 65% indicated a precise postoperative day answer; 35% of responses indicated a wide range. There were significant differences in duration of suction applied after pulmonary and oesophageal surgery, pulmonary and oesophageal surgery vs. empyema surgery and between wedge resection and VATS (P<0.05) (Fig. 2a).


Figure 2
View larger version (40K):
[in this window]
[in a new window]

  		Fig. 2. (a,b) Assessment of Chest Drainage System (CDCS). Results of the question: which are the standard duration of suction and maintenance of CDCS in your centre? (Section 7). (a) Graphic representation of the results related to the question: Stop suction and gravity drainage in relationship to the type of surgical procedure. Postoperative day – range: major lung resection=1–7; wedge resection=1–7; VATS=1–7; pneumothorax surgery=1–7; oesophageal cancer surgery=1–10; empyema=1–14; major lung resection vs. empyema P=0.000; wedge resection vs. pneumothorax surgery P=0.046; wedge resection vs. oesophageal cancer surgery P=0.008; wedge resection vs. empyema P=0.000; VATS vs. empyema P=0.000; VATS vs. pneumothorax surgery P=0.040; pneumothorax surgery vs. oesophageal cancer surgery P=0.006; pneumothorax vs. empyema P=0.000; oesophageal cancer surgery vs. empyema P=0.002. (b) Graphic representation of the results related to the question: remove drains. Postoperative day – range: Major lung resection=2–7; wedge resection=1–9; VATS=1–9; pneumothorax surgery=1–9; oesophageal cancer surgery=1–10; empyema=1–20. Major lung resection vs. wedge resection P=0.000; major lung resection vs. VATS P=0.000; major lung resection vs. oesophageal cancer surgery P=0.000; major lung resection vs. empyema P=0.000; wedge resection vs. oesophageal surgery P=0.000; wedge resection vs. pneumothorax surgery P=0.000; wedge resection vs. empyema P=0.000; VATS vs. pneumothorax surgery P=0.000; VATS vs. oesophageal cancer surgery P=0.000; VATS vs. empyema P=0.000; pneumothorax surgery vs. oesophageal cancer surgery P=0.000; pneumothorax surgery vs. empyema P=0.000.

 
3.7.4. Time to removal of drains
The 54.2% indicated a precise postoperative day answer; 45.8% indicated a wide range. There were significant differences in time to removal of drains after pulmonary and oesophageal surgery, pulmonary surgery and empyema, wedge resection and VATS (P<0.05) (Fig. 2b).


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
References
 
The survey showed a consistency of choice of chest drainage collection system between procedures of a similar type. We know that this is often based more on a surgeon's training than on scientific data [1, 2], and on an unwillingness to adopt new technological devices or protocols in preference to conventional systems and time-honoured practice [3].

The development of dry suction control chambers represents a further step in the evolution of chest drainage systems [1–4]. Results of this survey suggest the following improvements could be made in designing disposable CDCS: the high positive pressure relief valve could be both manual and automatic (41.4%), provision of a sterilising membrane (51.3%), the usefulness of a sequential tube clamp system allowing simultaneously to clamp the drainage connection tube, close the vacuum source, vent air into the fluid collection chamber, for temporarily closing aspiration and for preventing errors in manually venting high intrathoracic negative pressures (57.9%), the provision of an air leakage scale (53.5%), and the preference for a CDCS which automatically sets the level of suction according to the air-leak rate (77.7%).

Drainage after pneumonectomy is still controversial [5]. A balanced drainage system is most popular (51.2%). Suction was generally stopped by the 4th postoperative day regardless of operation type and drains removed by the 4th postoperative day, except in surgery for empyema (82.4%) and oesophageal resection (70.7%) [6–8], in keeping with the principal of space collapse in the former and drainage of potential leak in the latter [5, 9, 10].

The most desirable feature was simplicity of management of a system by nursing and trainee medical staff as well as cost effectiveness.

European centres

Austria University of Vienna Medical School, Department of Cardiothoracic Surgery, Vienna; Landesklinikum St. Pölten, Department of Cardio-Thoracic Surgery, St. Pölten.

Belgium The Antwerp University Hospital, Department of Thoracic and Vascular Surgery, Antwerpen-Edegem; Catholic University of Leuven, Department of Thoracic and Cardiovascular Surgery, Leuven; University Hospitals Leuven, Department of Thoracic Surgery, Leuven.

Czech Republic Charles University Hospital Motol, Department of Thoracic Surgery, Prague.

Estonia University Hospital of Tartu, Tartu.

France AP-HM Sainte Marguerite University Hospital, Department of Thoracic Surgery, Marseille; Hôpital Sainte Marguerite, Department of Thoracic Surgery, Marseille.

Germany ELK Chest Hospital, Department of Thoracic Surgery, Berlin; Vivantes KLinikum Neukölln, Department of Thoracic and Cardiovascular Surgery, Berlin; Fachkrankenhaus Coswig, Department of Thoracic and Vascular Surgery, Coswig; Lung Centre, Evangelic Hospital, Department of Thoracic and Vascular Surgery, Bielefeld; University Hospital of Freiburg, Department of Thoracic Surgery, Freiburg; Hannover Medical School, Department of Thoracic and Cardiovascular, Hannover; Klinikum Kassel, Department of Thoracic Surgery, Kassel; Katholisches Klinikum Koblenz, Department of Thoracic Surgery, Koblenz.

Greece General Hospital of Attica ‘K.A.T’, Department of Thoracic Surgery, Athens; ‘Sotiria’ Chest Diseases Hospital, Thoracic Surgery Department, Athens; 401 General Military Hospital of Athens, Department of Thoracic Surgery, Athens; ‘Evangelismos’ General Hospitals Department of Thoracic and Vascular Surgery, Athens; Larissa University Hospital, Department of Cardio-thoracic Surgery, Larissa; Patras University School of Medicine, Department of Cardiothoracic Surgery, Patras; Nicosia General Hospital, Department of Thoracic and Vascular Surgery, Cyprus.

Hungary Semmelweis Teaching Hospital, Department of General and Thoracic Surgery, Miskolc; Bács-Kiskun County Hospital, Department of General, Thoracic and Vascular Surgery, Kecskemét; University of Pécs, Medical Faculty, Department of Surgery, Thoracic Unit, Pécs.

Italy University of Bologna, Department of General Thoracic Surgery and Organ Transplantation, Bologna; University of Catania, Department of Thoracic and Cardiovascular Surgery, Catania; Santa Croce and Carle Hospital, Department of Thoracic Surgery, Cuneo; Careggi University Hospital, Thoracic Unit, Florence; European Institute of Oncology, Thoracic Surgery Unit, Milan; Scientific Institute San Raffaele Hospital, Department of Thoracic Surgery, Milan; University of Milan, Department of Surgery-Thoracic Unit, IRCCS, Milan; Maggiore della Carità Hospital, Thoracic Unit, Novara; Carlo Forlanini Hospital, Thoracic Surgery Unit, Rome; A. Gemelli Catholic University, Department of Cardiac Surgery, Rome; Regina Apostolorum Hospital, Department of Cardio-Thoracic Surgery, Rome; National Cancer Institute Pascale Foundation, Division of Thoracic Surgery, Naples; Second University of Naples, Thoracic Surgery Unit, Naples; University Hospital of Siena, Thoracic Surgery Unit, Siena; Civic Hospital, Thoracic Surgery Unit, Palermo; Villa Maria Cecilia Hospital, Division of Esophageal and Pulmonary Surgery, Cotignola, Ravenna; Villa Maria Cecilia Hospital, Division of Thoracic and Cardiovascular Surgery, Cotignola, Ravenna; University Hospital of Parma, Department of Thoracic Surgery, Parma; University of Padua Medical School, Section of Thoracic Surgery, Padua; Molinette Hospital, Department of Thoracic Surgery, Torino.

Latvia P. Stradins Clinical University Latvia Hospital, Department of Thoracic Surgery, Latvia.

Luxembourg Centre Hospitalier de Luxembourg, Department of Thoracic Surgery, Luxembourg.

Poland Poznan Regional Centre for Pulmonary Diseases, Department of Thoracic Surgery, Poznan; Pulmonary Hospital, Department of Thoracic Surgery, Zakopane; Regional Hospital for Lung Diseases, Department of Thoracic Surgery, Szczecin-Zdunowo; University Hospital of Krakòw, Department of General and Thoracic Surgery, Krakòw.

Romania National Institute of Pneumology ‘M. Nasta’, Thoracic Surgery Department, Bucuresti; Clinical Hospital ‘Leon Daniello’, Thoracic Surgery Department, Cluj-Napoca; Municipal Clinical Hospital, Clinic of Thoracic Surgery, Timisoara.

Russia Moscow Regional Clinical & Research Institute ‘MONIKI’, Department of Thoracic Surgery, Moscow.

Spain Hospital Universitari Sagrat Cor, Service of Thoracic Surgery, Barcelona; Hospital Clinico, University of Barcelona, Department of Thoracic and Cardiovascular Surgery, Barcelona; Hospital Universitari de Girona ‘Doctor Josep Trueta’, Department of Thoracic Surgery, Girona; Hospital Clìnico San Carlos, Department of Cardiovascular and Thoracic Surgery, Madrid; Xanit International Hospital, Thoracic Surgery Unit, Benalmádena; University Clinic Hospital, Department of Thoracic Surgery, Valencia; Hospital Universitario Miguel Servet, Department of Thoracic Surgery, Barcelona; Hospital Xeral-Cies of Vigo, Division of Thoracic Surgery, Vigo; Hospital Universitario de Canarias (HUC), Division of Thoracic Surgery, Canarias.

Switzerland S. Giovanni Bellinzona Hospital, Division of Thoracic Surgery, Bellinzona; Hirslanden Zürich Hospital, Department of Thoracic and Cardiovascular Surgery, Zürich.

The Netherlands Medical Spectrum Twente, Department of Cardio-Thoracic Surgery, Enschede; Ziekenhuis Riviereland, Department of Cardio-Thoracic Surgery, Tiel; VU University Medical Centre, Department of Thoracic and Cardiac Surgery, Amsterdam.

Turkey Faculty of Medicine, Department of Thoracic Surgery, Izmir; Ibn-i Sina Hospital, Ankara University School of Medicine, Department of Thoracic Surgery, Ankara; Gaziantep University Medical School, Department of Thoracic Surgery, Gaziantep; Marmara University, Department of Thoracic Surgery, Istanbul; Goverment Hospital, Thoracic and Cardiovascular Surgery Department, Izmit; VKF American Hospital, Department of Thoracic Surgery, Istanbul; Sureyyapasa Thoracic Diseases and Thoracic Surgery Teaching and Investigation Hospital, Istanbul; Uludag University School of Medicine, Department of Thoracic Surgery, Bursa; Yedikule Hospital for Chest Diseases and Thoracic Surgery, Istanbul.

United Kingdom Royal Victoria Hospital, Department of Thoracic Surgery, Belfast; Bristol Royal Infirmary, Cardiac Unit and Thoracic Unit, Bristol; Royal Exeter and Devon Hospital, Department of Thoracic Surgery, Exeter; The Cardiothoracic Centre, Department of Cardio-Thoracic Surgery, Liverpool; Freeman Hospital, Department of Cardio-Thoracic Surgery, Newcastle; Norfolk and Norwich University Hospital NHS Trust, Department of Cardio-Thoracic Surgery, Norwich; Nottingham City Hospital, Department of Thoracic Surgery, Nottingham.

Yugoslavia University Surgical Hospital, Department of Thoracic Surgery, Split, Croatia; Sarajevo University Clinical Hospital, Department of Thoracic Surgery, Sarajevo; University Medical Centre Ljubljana, Department of Thoracic Surgery, Ljubljana, Slovenia; Institute for Lung Diseases Sremska Kamenica, Division of Thoracic Surgery, Vojvodina, Serbia and Montenegro.


   References
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
 References
 

  1. Laws D, Neville E, Duffy J. BTS guidelines for the insertion of a chest drain. Thorax 2003;58(Suppl_II):ii53–ii59.[Free Full Text]
  2. Munnell ER. Thoracic Drainage. Ann Thorac Surg 1997;63:1497–1502.[Abstract/Free Full Text]
  3. Ueda K, Sudoh M, Jinbo M, Li TS, Suga K, Hamano K. Physiological rehabilitation after video-assisted lung lobectomy for cancer: a prospective study of measuring daily exercise and oxygenation capacity. Eur J Cardio-thorac Surg 2006;30:533–537.[Abstract/Free Full Text]
  4. Cerfolio RJ, Bass CS, CRNP, Pask AH, Katholi CR. Predictors and treatment of persistent air leaks. Ann Thorac Surg 2002;73:1727–1731.[Abstract/Free Full Text]
  5. Meyer JA. Gotthard Bülau and closed water-seal drainage for empyema, 1875–1891. Ann Thorac Surg 1989;48:597–599.[Abstract]
  6. Cerfolio RJ, Bass C, Katholi CR. Prospective randomized trial compares suction versus water seal for air leaks. Ann Thorac Surg 2001;71:1613–1617.[Abstract/Free Full Text]
  7. Cerfolio RJ, Pickens A, Bass C, Katholi C. Fast-tracking pulmonary resections. J Thorac Cardiovasc Surg 2001;122:318–324.[Abstract/Free Full Text]
  8. Anegg U, Lindenmann J, Matzi V, Mujkic D, Maier A, Fritz L, Smolle-Jüttner FM. AIRFIX: the first digital postoperative chest tube airflowmetry – a novel method to quantify air leakage after lung resections. Eur J Cardio-thorac Surg 2006;29:867–872.[Abstract/Free Full Text]
  9. Cerfolio RJ. Recent advances in the treatment of air leaks. Curr Opin Pulm Med 2005;11:319–323.[CrossRef][Medline]
  10. Cerfolio RJ, Tummala RP, Holman WL, Zorn GL, Kirklin JK, McGiffin DC, Naftel DC, Pacifico AD. A prospective algorithm for the management of air leaks after pulmonary resection. Ann Thorac Surg 1998;66:1726–1731.[Abstract/Free Full Text]

Related Article

eComment: A tribute to Gotthard Bülau and Vincenzo Monaldi
Karsten Knobloch
Interactive CardioVascular and Thoracic Surgery 2008 7: 1159. [Full Text] [PDF]



This article has been cited by other articles:


Home page
 ICVTSHome page
K. Knobloch
eComment: A tribute to Gotthard Bulau and Vincenzo Monaldi
Interactive CardioVascular and Thoracic Surgery, December 1, 2008; 7(6): 1159 - 1159.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Sandro Mattioli
Richard G. Berrisford
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Google Scholar
Right arrow Articles by Mattioli, S.
Right arrow Articles by Aramini, B.
PubMed
Right arrow PubMed Citation
Right arrow Articles by Mattioli, S.
Right arrow Articles by Aramini, B.
Related Collections
Right arrowRelated Article

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS