Management of Chest Tubes and Air Leaks after Lung Resection

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
 Waterseal
 Clamp Trial
 Actively suctions air and
fluid from chest cavity
Chest Tube Management
 Suction
 Waterseal
 Clamp Trial
 Passively allows fluid and
air to escape chest cavity
by gravity drainage
Chest Tube Management
 Suction
 Waterseal
 Clamp Trial
 Simulates the chest tube
being removed from the
patient to assess for a
silent airleak
Pleurovac Management
Suction Control
Chamber
Waterseal Chamber
Collection
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
Pigtail
 Size of chest tube
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
Esophageal
Surgery
Diaphragm
Surgery
Requires 24-72 hours suction to
optimize visceral and parietal pleura
with goal to obliterate space
Placed near
anastomosis in
case of leak
Suction
Waterseal
Helps decrease fluid
accumulation and
obliterate space
Suction
Common CT management Algorithm
after Lung Resection
No increasing pneumothorax
Waterseal
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
Airleak
Increasing pneumothorax
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
Completion
Pneumonectomy Pneumonectomy
Removal of the
affected lung and
lymph nodes
Removal of
remaining lung after
a prior lung
resection
Extrapleural
Pneumonectomy
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

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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
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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!