*Controversies in Pneumothorax Treatment DOI: http://dx.doi.org/10.5772/intechopen.87141*

*Pneumothorax*

**60**

**Figure 4.**

**Figure 3.**

*Multiple apical bullae hiding within an azygos lobe.*

of the previously mentioned systematic reviews alone.

hospital is ludicrous and logistically unachievable.

**5. Controversies surrounding chest drain insertion**

From the above discussion, it is unreasonable to assign increased recurrence rates to the way we access the chest cavity. Access should never matter. Minimal access surgery has leapt to the forefront of access choices preferred by patients. It has proven to result in less postoperative pain, less usage of analgesics and antiemetics, early recovery, less stay in hospital and early return to work. Therefore, it is very unlikely to advocate open thoracotomy as a first-choice procedure on the basis

*Bubbling test after stapling an apical bulla. More stapling was needed until the lung was watertight.*

Who should and who should not insert a chest drain? There is no consensus on this matter. However, surgical abilities even of a minor order are required to safely insert a chest drain; after all this is a surgical procedure. Therefore, proctored training is mandatory before any trainee is allowed to do it alone. Should one be certified before being allowed to perform this procedure unsupervised? This is debatable. Thoracic surgeons and their trainees are the most experienced to deal with chest drains; however, the idea that surgeons should look after all chest drains in the

The technique of drain insertion keeps changing. The BTS guidelines in 1993 recommend using a trocar (harpoon!); however, deaths had been reported from their use, and subsequently, the BTS changed its recommendations in an updated report in 2010 [10, 44]. Harris et al. reported on current practice and adverse incidents related to chest drains at 148 acute hospitals in the UK between 2003 and 2008 [45]. Thirty-one cases of chest drain misplacement were reported with seven deaths. Misplaced drains were inserted in the liver (10), peritoneal space (6), heart (5), spleen (5), subclavian vessels (2), colon (1), oesophagus (1) and inferior vena cava (1). One of my previous mentors at the University Hospital of Wales, the late Mr. Ian Breckenridge, has previously stated that "I regard trocar systems as potentially lethal weapons, and their misuse has been responsible for the few fatalities that I have seen, when heart, lung and liver have been lacerated" [46]. Similar serious injuries and fatalities were reported elsewhere [47–57]. Trocars are now banned from the UK. It is stating the obvious that the litigation expenses accompanying these cases are exorbitantly costly to the hospital trust and the taxpayer in the UK.

Clinicians differ about the choice of drain type and size [58]. Physicians and interventional radiologist tend to choose small calibre drains (medical drains), such as pigtails, 12F or 14F, whereas surgeons tend to put larger tubes +24F (surgical drains) [10, 59, 60]. Drain kinking, blockage and accidental dislodgment are common complications of small-bore drains (**Figure 5**). Per contra, Riber et al. in a retrospective study concluded that surgical (wide-bore) drains significantly increase the dwell time in primary SP [61]. Although they may be effective in managing pleural infection and less painful than large drains, small-bore drains may be less effective for pleurodesis [58]. The war between chest physicians and chest surgeons around the calibre of the chest drain will continue. Chest physicians have evidence that for air drainage size does not matter and a 16F drain is as good as any. Surgeons see the dysfunctional spectrum of these drains and correct the situation by inserting larger drains.

A persistent air leak with or without re-expansion of the lung is the usual reason for consideration of the use of suction, although there is no evidence for its routine use. The optimal level of suction on the drain is controversial, and so is the optimal time of its removal [62–66]. Data on the actual intrapleural pressure during the use of these systems is lacking [67]. Most of the knowledge is extrapolated from studies after lung resection, and protocols for pneumothorax drain insertion are scanty. It seems that the practice is a personal preference rather than evidence driven. We tend to believe that initial suction will guarantee the full expansion of lung and improves the chances of pleurodesis.

Recent introduction of the digital drainage systems seems to offer more physiological and dynamic mobile suction, assisting in enhanced early recovery [68, 69]. Its

## **Figure 5.**

*Dysfunctional medical drain (14F) removed to insert a surgical drain (28F) for pneumothorax. Twisting and overtight anchorage stitch obliterated the drain lumen.*

routine use has been recommended by the National Institute for Health and Clinical Excellence (NICE) after VATS pulmonary resections [70]. For how long should we leave the drain? One day, 1 week or more? Some believe (including the author) that if the drain is not serving its purpose, it should be removed. It is our practice to remove the drain the day following the surgery, provided the digital drain registers absence of air leak and the lung is fully expanded on the chest X-ray. The backdrop of such an approach is to accept reinsertion of the drain in a minority of patients when we get it wrong. The patient is allowed home after a normal chest X-ray has followed the drain removal. Others are more conservative and of the opinion that for the pleurodesis to succeed, the drain should remain in situ 3–7 days. We tend to send patients home with a Heimlich valve (flutter bag) if air leak persists more than 3 days and follow them weekly in the outpatient clinic. There are no RCTs to compare drain dwell times, and therefore general rules apply. In the absence of air leak while suction is off, and the lung is fully expanded on the chest X-ray the drain could safely be removed, otherwise; recurrence of pneumothorax is guaranteed.

There is a general consensus that drains should never be clamped [10, 71]. However, some of us do clamp drains and send patients to the radiology department for a chest X-ray, in preparation for removing the drain *despite* the air leak. It must be emphasised that this management should remain selective. This "provocative" approach in removing the drain despite air leak was described before by Kirschner et al. and Cerfolio et al. [72, 73]. If the chest X-ray shows the lung stuck to the chest wall after 2 weeks of tube time, we clamp the tube and send the patient for another X-ray. If the patient is clinically well and there is no change in lung expansion, then the drain is safely removed without bothering to close the drain site, which is usually either infected or has necrotic margins that take stitches badly. A pressure dressing is all that is needed. The stuck lung does not collapse, and the drain site closes in a week or two by secondary intention. The patient has to be reassured about the hissing sound through the drain site, which stops within a week or so.

To complicate matters further, air could entrain back into the chest at the time of drain removal. This usually leads to a small residual pneumothorax, which does not expand on subsequent radiological examination. It is important to realise the difference between erroneous drain removal and recurrence of genuine air leak. The incidence of this complication is technique-dependant and proportional to the experience of the staff member allocated for this task. Instructions given to the patient at the time of removing the drain are crucial. Again RCT about removing chest drains on full inspiration, full expiration, mid inspiration or Valsalva manoeuvre found no statistical difference, and therefore no evidence-based practice could be extrapolated [73, 74]. The rate of absorption of air in the chest is roughly 1–2% of the volume of the hemithorax every 24 hours, and complete re-expansion usually takes 2–7 weeks [75]. However, this might be too late for pleurodesis. By that time the parietal pleura (in the case of pleurectomy) would have healed, and the partially collapsed lung would not stick to the chest wall. Likewise, pleurodesing agents might be diluted or washed away by the reactive effusion, resulting in treatment failure.

From the above discussion, it is safe to conclude and agree with Lim that "No single aspect of postoperative care in general thoracic surgery is subject to more variation than the management of chest drains, … yet almost all thoracic surgeons and institutions manage chest drains differently" [76].
