Chest tube provocative clamping in patients having moderate or intense air leaks after lung resection to accelerate recovery

Introduction

Prolonged air leak (PAL) is a common complication after elective pulmonary resection and can lead to extended hospital stays and other complications (1). Thus, PAL is associated with significant economic and healthcare burdens (2). The general definition of PAL is air leak that persists for >5 days, and the reported incidence of PAL after pulmonary resection performed with video-assisted thoracoscopic surgery (VATS) is 6–15% (3-5). Several intraoperative and postoperative techniques have been developed to reduce the risk of PAL, which include fissure-less VATS (6,7), sealant application (8), indocyanine green sealing test (9,10), electronic suction equipment (11-14), and comprehensive management strategies (4,15-17). Some studies have indicated that in patients whose chest tube cannot be removed promptly after surgery, the patient may return home with the chest tube or a Heimlich valve and return for chest tube removal at a later time (18,19).

In 1992, Kato et al. reported that the chest tubes of five patients with PAL could be removed after clamping (20). Additionally, Kirschner et al. reported that “provocative clamping” could be used to guide chest tube removal despite persistent air leak (21). In 2001, Cerfolio et al. also reported that provocative clamping as a safety evaluation was followed by safe chest tube removal in 9 patients with continuous air leak for >14 days (22). However, provocative clamping has not been evaluated in terms of guiding early chest tube removal in patients who have undergone VATS lobectomy. Therefore, we retrospectively evaluated the safety and effectiveness of provocative clamping for patients with air leak during the early postoperative period. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1871/rc).

Methods

This retrospective single-center study included patients from Guangdong Provincial People’s Hospital who underwent elective lobectomy, bilobectomy, and segmentectomy between September 2022 and October 2023. All operations were performed by a single general thoracic surgeon (S.D.) to ensure full compliance with the protocol. Patients were excluded if they underwent pneumonectomy and wedge resection (because of the lower PAL incidence) or sleeve lobectomy (to minimize confounding parenchymal and anastomotic air leaks) or if they experienced other complications that delayed chest tube removal. Data were collected retrospectively, and follow-up surveillance was performed using our office’s system. Patients were asked to undergo chest radiography 1 month after the operation and to report their status through a website (https://jk.qitaijk.cn) or through a mobile phone application. Due to the retrospective nature of the analysis, the requirement of informed written consent was waived. The study protocol was approved by the institutional review board of Guangdong Provincial People’s Hospital (No. GDREC2020295H). This study was conducted in accordance with the Declaration of Helsinki (as revised in 2013).

All patients received standard intraoperative management for multiportal VATS, and incomplete fissures were stapled or divided using electrocautery at the surgeon’s decision. Patients with lung cancer underwent systematic lymph node dissection. After completion of the pulmonary resection, the chest was filled with saline solution, and the remaining lung was inflated. Air leaks were identified and sewn if the bubbles were obvious, although no sealants or buttressing materials were used. One chest tube (20 Fr) was placed posteriorly through the incision for the video device, a water seal was established, and the patient was transferred to a recovery unit for a few hours and subsequently transferred to the thoracic surgical ward. All patients received postoperative analgesia via an analgesic pump, with intravenous or oral analgesic treatment applied if needed to attain a visual analogue score of <4 for pain (total possible score of 10). Chest radiography was performed on postoperative day 1 while the patient had a water seal, and suction was not routinely used for pleural drainage unless there was >30% pneumothorax based on the radiographs. The tube was then converted to 10 cm of suction, and pneumothorax was evaluated on postoperative day 2.

Provocative clamping management

The presence of air leak was checked on postoperative day 1 or 2 routine ward rounds when the radiograph showed no obvious pneumothorax. Patients were fully mobilized and had sufficient pain relief to allow for coughing. The patient was instructed to repeatedly attempt forced expiration and coughing, and any air leak was graded on a 5-point scale (23). The chest tube could be removed in cases with grade 0–1 air leak (no air bubble to more than one on three serial volitional coughs), no apparent pneumothorax, and pleural effusion of <200 mL. Provocative clamping was started in cases with grade 2–4 air leak (persistent air bubbles on volitional coughs or spontaneous respiration) without pneumothorax. This procedure involved clamping of the chest tube on postoperative day 1 or 2, and chest radiography was performed 24 hours later (with clamping) if the patient did not develop subcutaneous emphysema, shortness of breath, or chest pain. If the radiograph showed no signs of worsened pneumothorax, the chest tube could be removed even if the air leak persisted. Repeat chest radiography was performed 24 hours later and the patient could be safely discharged if there were no signs of new or worsened pneumothorax. For those patients whose tube could not be removed after clamping, the tube was reopened, observed for 12–24 hours, and then clamped again. PAL was defined as an air leak lasting for >5 days postoperatively, as defined in the Society of Thoracic Surgeons (STS) National Database (4).

Statistical analysis

Continuous variables are reported as the median and range, while categorical variables are reported as numbers and percentages. The chi-square test was used to analyze categorical data, while the Wilcoxon test was generally used to analyze continuous data except for body mass index, which was analyzed with the Student t-test. All statistical analyses were performed using SPSS version 24.0 software (IBM Corp., Armonk, NY, USA).

Results

This study included 74 patients, with 3 patients being excluded (2 with chylothorax in 2 and 1 with postoperative blood loss). Sixty-six of them received lobectomies/bilobectomies and 11 received segmentectomies via VATS. Lung cancer was the most common (72 patients) postoperative diagnosis (Table 1).

All patients underwent chest radiography on postoperative day 1, and 65 patients had no apparent pneumothorax (<30%) and were evaluated for air leak. Nine patients (12%) required pleural suction due to large pneumothorax and so were not evaluated for air leak until the radiographs revealed no signs of obvious pneumothorax. Based on the bedside air leak evaluation, patients were assigned to a low-air leak group (grade 0–1: 53 patients) or a high air-leak group (grade 2–4: 21 patients). There were no significant differences in the groups’ baseline characteristics, although upper lobe resection was more common in the high-air leak group. In the low-air leak group, the chest tube was removed when pleural effusion was <200 mL/day. No patients exhibited signs of enlarged pneumothorax on the chest radiographs at 24 hours after chest tube removal.

All 21 patients in the high-air leak group had their chest tubes clamped, and 11 were asymptomatic after >24 hours of clamping, with chest radiographs revealing no or minimal pneumothorax. In these cases, the chest tubes were removed regardless of the air leak status when the chest tube was reopened. Five patients developed mild shortness of breath, pain, or progressive subcutaneous emphysema when their chest tubes were clamped. Whereas, five patients were asymptomatic, although their chest radiographs revealed increased pneumothorax. A water seal was applied for 12 hours in these 10 patients, and then the tubes were clamped again, which resulted in 8 patients fulfilling the criteria for chest tube removal. The remaining two patients had their tubes alternately opened and clamped until removal. The study flowchart is shown in Figure 1. Chest radiography was performed at 24 hours after chest tube removal, which revealed 20 patients had no or reduced pneumothorax. One patient had minimally increased pneumothorax (10% increase) but was asymptomatic and so did not require additional treatment. No patients exhibited massive lung collapse.

Figure 1 Study flowchart. ^#, nine patients required pleural suction for large pneumothorax. The air leak evaluation was not performed until these patients had no obvious pneumothorax observed based on the chest radiographs. *, ten patients underwent repeated clamping.

Among all patients, the mean chest tube insertion duration was 2.5 days (range, 1–7 days), and the mean hospital length of stay was 4.0 days (range, 1–8 days). The mean chest tube insertion duration was 2.2 days (range, 1–5 days) in the low-air leak group and 3.2 days (range, 2–7 days) in the high-air leak group. The mean hospital length of stay was 3.7 days (range, 1–6 days) in the low-air leak group and 4.5 days (range, 3–8 days) in the high-air leak group. Only 1 patient (1.3%) developed PAL, and this patient had a grade 4 air leak. The chest tube was alternately clamped and opened until no pneumothorax was observed, and the tube was ultimately removed on postoperative day 8. One patient in the high-air leak group, who had undergone left upper lobectomy, was readmitted to our hospital at 3 weeks after discharge due to shortness of breath. Chest radiographs revealed hydropneumothorax that required reinsertion of chest drains. The air leak was grade 3 when the chest tube was inserted, the provocative clamping method was once again applied, and no pneumothorax occurred. The chest tube was removed 3 days later, and the patient did not exhibit any signs of pneumothorax at the follow-up. No other patients had increased pneumothorax according to the 1-month follow-up radiographs.

Complications in the low-air leak group included one case of atrial fibrillation, one case of atelectasis, and one case of abdominal pain. The only complications in the high-air leak group were related to the chest tube clamping.

Discussion

Postoperative chest tube management is of utmost concern to thoracic surgeons. Our previous study revealed that routine chest tubes could be replaced by prophylactic air-extraction catheters for patients undergoing wedge resection (24). This strategy reduces patients’ postoperative pain and postoperative hospital stay in our clinical practice, but some patients still experience substantial air leak after lobectomies or segmentectomies, which delays the removal of the chest tube. Some researchers have shown that a chest tube can be removed after provocative clamping even if air leak lasts for 2–3 weeks after the operation (20,22). Provocative clamping has been used to evaluate patients’ potential response to chest tube removal, and patients who pass this assessment can have their chest tube removed safely. However, this test has not been evaluated during the early postoperative period after pulmonary resection. This study found provocative clamping to be safe and effective in 21 patients with apparent early postoperative air leak, which we defined as grade 2–4. Among these patients, 20 patients had their chest tube removed within 4 days postoperatively, and only 1 of the 74 enrolled patients (1.4%) experienced PAL, representing an incidence lower than that in previous reports (3-5,25).

Provocative clamping is an aggressive technique for managing air leaks, with tension pneumothorax being the most dangerous among the related complications. However, air leaks are generally small in cases of elective pulmonary resection, and the clamp can be removed easily and quickly, so there is minimal risk for these patients. In our cohort, five patients had newly developed pneumothorax, and five patients developed symptoms (e.g., shortness of breath or chest pain) or subcutaneous emphysema, which resolved after reopening of the chest tube. For these patients, after an observation of 12–24 hours, the chest tube was clamped again. We noticed that most of these patients had fewer symptoms and less-severe pneumothorax during the second chest tube clamping, which suggests that the clamping process accelerated alveolopleural fistula healing. The occurrence of pneumothorax after discharge is one of the most common reasons for readmission (3) and is also a potential concern related to provocative clamping. In our study, the tubes were clamped for 24 hours before removal and then observed for 24 hours after removal; no patients exhibited increased pneumothorax during these 24-hour observation periods. Only one patient developed worsened shortness of breath, and chest radiographs revealed midvolume hydropneumothorax at 3 weeks after discharge. Thus, our findings suggest that provocative clamping is potentially safe for patients who have air leaks in the hospital and after discharge.

Provocative clamping was initially used for patients with air leak that persisted for >2–3 weeks. In this context, lung adhesions form and prevent pneumothorax from developing, which makes removal of the chest tube safe despite the presence of air leak (22). However, we consider the mechanism of provocative clamping to be different when performed for early postoperative air leak. In theory, placing chest tubes on suction improves the apposition of the visceral and parietal pleurae, which facilitates the sealing of air leaks. However, several studies have indicated that suction is not superior to water seal for the management of air leak (26-29). The possible reason for this is that a leak that is only visible upon forced expiration is likely converted to a near-continuous leak that is proportional to the amount of suction when suction is applied. In contrast, a lack of suction likely leads to a decreased volume of air leaking from the parenchyma through the water seal, which allows for the sealing of the leak, as the cells can more readily bridge the gap (26-30). Therefore, we further speculated that when the tube is clamped, air flows through the lung parenchyma to the pleural space, pneumothorax develops and increases the pleural pressure, and the lung collapses, which leads to the reduction of the fistula and airflow. With pneumothorax no longer worsened when the air pressure between the alveolar and pleural cavities reaches equilibrium and with only minimal air flow through the fistula, healing of the pleura is accelerated (Figure 2).

Figure 2 Mechanism of pneumothorax stabilization and alveolopleural fistula healing through pressure equilibration. (A) The alveolar air pressure is greater than the pressure in the pleural cavity, which leads to pneumothorax. (B) With the alveolar and pleural cavity pressures balanced, pneumothorax no longer increases, and the healing of the alveolopleural fistula accelerates. White arrow: alveolar pressure; black arrow: pleural pressure.

One study has indicated that patients with air leak can be sent home with a Heimlich valve, and that the tube can be removed in an outpatient clinic if the chest radiograph reveals no pneumothorax expansion or other symptoms (22). Bao et al. have also reported that patients can be safely discharged with a chest tube although these patients may require a prolonged time with the chest tube (19). However, the tube and drainage system may be an annoyance to many patients, and a lack of home healthcare can make patients hesitant to leave the hospital early. Thus, provocative chest tube clamping may help guide early and safe tube removal during the original hospitalization, which may improve patient satisfaction without increasing the cost of treatment. The fissure-less technique is considered a superior alternative to conventional lobectomy in terms of preventing PAL (7,30,31). We speculate that conventional lobectomy is more favorable in terms of exposing the pulmonary arteries and lymph nodes in the fissured parenchyma, requiring fewer stapler firings, and ensuring the staple lines do not restrict the full expansion of the remaining lung. Therefore, we routinely perform conventional surgical procedures in our institution. Although these techniques are associated with an increased risk of air leak, it appears that provocative clamping can help lower the incidence of PAL with conventional surgical procedures.

The Robert David Cerfolio classification system is the most cited system for classifying air leak, and randomized trials have confirmed its accuracy (27,32,33). Chest tube drainage systems that contain a digital air leak meter have also been developed although they require an extra drainage system and are associated with increased costs (4,11,14). In contrast, we used a simplified five-point grading method to evaluate air leak (23), which we acknowledge is not a precise method and is subject to the idiosyncrasy of the observer. However, this method functions to distinguish between patients with and without obvious air leak and to screen for potential PAL cases. In our study, the tubes of patients in low-air leak group were removed without any intervention, and chest radiographs confirmed that none of the patients had increased pneumothorax after chest tube removal.

The limitations of our study include its single-center, retrospective design. Furthermore, a single surgeon performed all procedures, which although this increased the consistency regarding surgical technique and postoperative interventions, it also limited the generalizability of the results. Randomized controlled trials are needed to examine individual components of the air leak reduction protocol.

Conclusions

Our study revealed that the provocative clamping procedure is safe and effective for managing early air leak after pulmonary resection.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1871/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1871/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1871/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1871/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki (as revised in 2013) and was approved by the institutional review board of Guangdong Provincial People’s Hospital (No. GDREC2020295H). Individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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