MMCTS
(April 9, 2009). doi:10.1510/mmcts.2007.003129
Copyright © 2009 European Association for Cardio-thoracic Surgery
Procedure
The quantification of postoperative air leaks
Robert J. Cerfolio* and
Ayesha S. Bryant
Division of Cardiothoracic Surgery, University of Alabama at Birmingham (UAB), 703 19th St S, ZRB 739, Birmingham, AL 35294, USA
* Corresponding author: Tel.: +1-205-934-5937; fax: +1-205-975-2815. robert.cerfolio{at}ccc.uab.edu
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Summary
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Air leaks are one of the most common complications after pulmonary resection and they are the most frequent cause of prolonged hospital stay, increased cost and patient dissatisfaction. The management of chest tubes in patients with air leaks is optimized when the air leak is scientifically evaluated. The traditionally used analogue classification system, the Robert David Cerfolio Classification System (or RDC named after my father) has inherent subjectivity to it and may be interpreted differently by different bedside observers. More recently, several companies have developed digital pleural drainage systems that are able to quantify the size of air leaks in ml/min or in ml/breath. This eliminates the subjectivity. This affords better interpretation of chest tube setting changes and of air leak healing. These units also provide recordings of the air leak and of the pleural pressure. In this multimedia chapter, we report the different methods of measuring air leaks.
Key Words: Air leak • Pulmonary resection • Suction • Water seal
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Introduction
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Alveolar-pleural fistulas (air leaks) remain one of the most common complications after pulmonary resection. Over the past several years others along with ourselves have studied this problem. We have used prospective randomized trials or predetermined algorithms in an attempt to bring some science to what has been, until recently, mainly a subjective art. We created an air leak classification system, the Robert David Cerfolio (RDC) Classification System – named after my father – and it has been reliable and has become an important component of patient care [1]. We have seen the RDC Classification System successfully employed in many hospitals all over the world yet it remains an analogue system and hence has some inherent subjectivity. In many facets of our lives, digital systems have replaced analogue systems. They provide more accurate and easily readable data. Patient's temperature, blood pressure and other signs are all reported using digital systems now. It makes sense that the pleural space and air leaks have a similar fate. Over the past few years, two companies have developed digital devices that allow for the continuous and digital measurement of air leaks and of the pleural space pressure. We have studied both systems and have performed and published the first prospective study that shows that one of these devices may shorten hospital stay by improving the care of air leaks by better directing chest tube management [2]. This occurred because of the more accurate measurement of air leaks and management of the pleural space. These devices almost certainly represent the future of chest tube drainage systems, if the price is not prohibitive.
In this multimedia chapter we will present video recordings of patients with air leaks as displayed by a traditional analogue air leak meter using the well described, patient tested and clinical verified RDC system which is measured by the Sahara S-11000 (Teleflex, Research Triangle Plus, NC, USA) system. This drainage system features a seven-column air leak meter within it, as shown in Photo 1 (Sahara S-11000) below.
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Results
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Sahara system
We have performed many trials using a "traditional" pleural drainage system that has a self-contained air leak system. This system is shown in Photo 1.
The basic import of many of these studies is that the water seal is not only a safe chest tube setting for patients with air leaks but leads to quicker healing of the air leak if the air leak is small (FE 3 or smaller in the RDC classification system) [3, 4, 5, 6, 7].
Digivent system
More recently we have studied, in a prospective fashion, the new digital device, the Digivent (Millicore, Sweden) system [2]. A picture of this device and the curves and data it can generate concerning the maximum and minimum pleural space pressures are shown in Photo 2.
This quantifies the air leaks in ml/min. The average size of the air leak can be displayed over the last 1, 3 or 6 h or in whatever time increments are chosen by the physician. This affords the physician the ability to assess air leak healing. It also is the only unit that provides information about the maximum and minimum pleural pressures as shown in Photo 2 (The Millicore Digivent system and the readout). In this prospective study [2], 98 patients that underwent elective pulmonary resection were randomized to either the digital Digivent system or the analogue, Sahara system. Pulmonary function, types of pulmonary resection, number of chest tubes, and pathology were not statistically different between the groups. The digital system confirmed the air leak status in five patients that were equivocal on the analogue system. The ability to assess the air leak status continuously afforded quicker chest tube removal in the digital group (mean, 3.1 vs. 3.9 days, P=0.034) and reduced hospital stay (mean, 3.3 vs. 4.0 days, P=0.055) as shown in Table 1 below.
Another important finding was that the unproven, unverified digital scale linearly correlated with the clinical proven and tested (RDC scale, r2=0.80; regression equation: y=2.094+0.0061x). Based on those findings, we implemented chest tube management based on air leak size as shown below in Table 2.
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Thopaz
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We performed another prospective study on a different chest drainage system called the Thopaz (Photo 3).
This system also quantifies the size of an air leak into a number in ml/breath. Not only does this system display air leaks digitally in cc/min, but in addition, it also is able to provide suction (if needed) as a patient ambulates. In this study, we had patients undergo elective pulmonary resection and their tubes were placed to either the digital drainage system, which quantifies the air leak in cc/min, or to an analogue system that features a seven-chamber air leak meter and had similar chest tube management schemes applied. There were 98 patients (48 received digital system, 50 the air leak meter). Patient age, body mass index, pulmonary function tests and types of procedures were similar in both groups. A brief tabular summary of this yet unpublished study (publication pending) is shown below in Table 3. For publication reasons we cannot show all of the results of this study.
The usefulness of these studies and new technology are displayed in Videos 123 4.
Click on image to view video |
Video 1 This clip shows a patient who underwent a left lower lobectomy and has an air leak. He is asked to breath in and out, notice that there is little variation in the digital output.
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Click on image to view video |
Video 2 This clip shows this same patient. He is asked in this segment to take a deep breath in and out. There is very little shift in fluid.
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Click on image to view video |
Video 3 This same patient asked to cough – note that he has a FORCED EXPIRATORY 5 air leak. Also note the inherent subjectivity in assessing if it is a 5 or 6 size leak.
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Click on image to view video |
Video 4 This video clip shows the same patient as above, this time he is placed on a Digivent system and asked to perform the same manoeuvres (breath in, breath out). Note the air leak readings are greater and fluctuate greater than with the Thopaz system.
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Discussion
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As shown above, the treatment of air leaks continues to evolve and it has led to improved chest tube management through the use of scientific study instead of opinion, dogma and stubborn conjecture. This has led to the earlier removal of chest tubes, decreased pain and morbidity and the early discharge of patients, a small percentage of whom can go home with a chest tube in place because of a prolonged air leak. There is little question in our opinion that digital air leak devices are the future of the bedside management of air leaks, however, there are many unanswered questions concerning which patients need them, which do not and what is the cost savings. Further studies are needed to help answer these important questions which surgeons are faced with every day all over the world.
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Footnotes
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 Financial disclosures: Robert Cerfolio: Medela (Speaker), Millicore (Consultant, Speaker), Teleflex (Consultant). 
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References
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- 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]
- Cerfolio RJ, Bryant AS. The benefits of continuous and digital air leak assessment after elective pulmonary resection. A prospective study. Ann Thorac Surg 2008;86:396–401.[Abstract/Free Full Text]
- 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]
- Marshall MB, Deeb ME, Bleier JI, Kucharczuk JC, Friedberg JS, Kaiser LR, Shrager JB. Suction vs. water seal after pulmonary resection: a randomized prospective study. Chest 2002;121:831–835.[Abstract/Free Full Text]
- Cerfolio RJ. Recent advances in the treatment of air leaks. Curr Opin Pulm Med 2005;11:319–323.[CrossRef][Medline]
- Cerfolio RJ, Bryant AS, Singh S, Bass CS, Bartolucci AA. The management of chest tubes in patients with a pneumothorax and an air leak after pulmonary resection. Chest 2005;128:816–820.[Abstract/Free Full Text]
- Brunelli A, Monteverde M, Borri A, Salati M, Marasco RD, Al Refai M, Fianchini A. Comparison of water seal and suction after pulmonary lobectomy: a prospective, randomized trial. Ann Thorac Surg 2004;77:1932–1937.[Abstract/Free Full Text]
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Summary
Introduction
