EAST 2014: The Dogma Of Putting Chest Tubes To Suction?

Chest trauma is a very common occurrence. One of the more common procedures for managing it is insertion of a chest tube. In the majority of cases, the drain is connected to a system to collect blood and vent air. And they are nearly always automatically hooked up to 20cm of suction.

A study was constructed to randomize the use of suction vs water seal in patients with pneumothorax, hemothorax, or a combination of both. Patients who had early positive pressure ventilation (ventilated, emergency OR), chronic lung disease, or severe TBI (?) were excluded.

Here are the factoids:

110 patients were randomized to either water seal (54) or 20cm of suction (56)
There was no difference in the length of time the tube was in place between the groups (3 days)
Incidence of retained hemothorax and empyema was no different (and hopefully rare!)
Hospital length of stay was the same
There was a significantly increased incidence of persistent air leak in the suction group

Bottom line: First, this is a small study so it doesn’t have enough power to make definitive statements. However, it is definitely provocative. We blithely put every patient on suction, not thinking about the negative implications such as decreased mobility, increased atelectasis, and DVT. Patients on suction are much less likely to move around at all! A mobile patient is just as likely to push any air and blood out of the tube as an immobile one is to have it sucked out. Let’s do a larger study to confirm this! And hey, use a protocol to manage the tube! Three days is too long to have a tube in place.

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Reference: Negative pleural suction in thoracic trauma patients: a randomized controlled trial. EAST 2014 oral paper 14.

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