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Ann Thorac Surg 1997;64:1437-1440
© 1997 The Society of Thoracic Surgeons

Original Articles: General Thoracic

Outpatient Chest Tube Management

Ronald B. Ponn, MD, Howard J. Silverman, MD, John A. Federico, MD

Sections of Cardiothoracic Surgery, The Hospital of St. Raphael, and Yale-New Haven Hospital, New Haven, Connecticut

Accepted for publication May 9, 1997.


   Abstract
Top
 Footnotes
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Background. Patients with indwelling chest tubes inserted for the purpose of evacuating pleural air traditionally are treated in the hospital. The current emphasis on cost-effective medical care and a recent report describing the early discharge of patients who had undergone lung volume reduction operations and had a persistent air leak prompted us to review our overall experience with outpatient tubes in a general thoracic surgical practice.

Methods. We reviewed the records of patients who had been discharged from the hospital with chest tubes and Heimlich valves in place for venting pleural air over the past 7 years. Ambulatory tube management was used on a total of 240 occasions in three diagnostic groups: pneumothorax (176 cases), prolonged postresection air leak (45 cases), and outpatient thoracoscopic pulmonary wedge excision (19 cases). Failure was defined as hospital admission for complications of tube insertion or function.

Results. There were 10 failures in the entire group (4.2%), 4.5% for pneumothorax, 2% for postresection air leak, and 5.3% for outpatient thoracoscopy. There were no deaths or instances of life-threatening problems. The cost of at least 1,263 inpatient hospital days was saved.

Conclusions. The presence of a chest tube, with or without an air leak, does not always require hospitalization. Admission can be avoided in most patients with primary spontaneous pneumothorax and in selected patients with pneumothorax of other causes. The postoperative hospital stay can be shortened for many patients who have a prolonged air leak after pulmonary resection. Ambulatory tube management also makes feasible outpatient thoracoscopy for noneffusive processes.


   Introduction
Top
 Footnotes
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
The expense of hospitalization and the current focus on cost-effective care mandate that outpatient treatment be considered when patient comfort and clinical outcome are not compromised by this approach. When hospital admission is necessary, its duration may be minimized if ongoing problems can be addressed at home or in a subacute care facility. Thoracic surgeons for decades have been comfortable with the use of outpatient pleural drains or "empyema tubes" to vent chronic fixed intrapleural spaces. Despite reports of ambulatory tube management for pneumothorax [1, 2], however, many remain reluctant to consider outpatient catheters for the evacuation of air from a nonfibrosed hemithorax. Concerns are based on the possibility of clinical compromise from lung collapse, prolongation of air leak as a result of failure of pleural apposition, and fear of empyema. McKenna and associates [3] recently reported the use of the Heimlich flutter valve to shorten the hospital stay after lung volume reduction. Their favorable results prompted us to review our experience with the Heimlich valve in three other areas of general thoracic surgical practice: pneumothorax, postresection air leak, and outpatient thoracoscopy.


   Material and Methods
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
We reviewed the records of our patients during the past 7 years who were followed up on an ambulatory basis with chest tubes in place for the evacuation of pleural air. Patients with open drains for empyema or with space problems and catheters for pleural effusion were not included. Recorded data included age, sex, procedure, presence or absence of an air leak, duration of outpatient use, complications, and hospital admissions. Failure was defined as hospital admission because of problems with tube insertion or function. Patients admitted for operation because of an uncomplicated prolonged air leak were not considered to be failures, because the same outcome would have been expected if they had been treated in the hospital.

For pneumothorax, a standard anterior second interspace or axillary tube thoracostomy using a 12F or 16F short (10-in.) catheter is performed in the office, emergency department, or radiology suite. To prevent kinking, it is essential that the tube be placed intracorporeally for most of its length, with only 1 or 2 cm plus the flared end left outside the body. A Heimlich valve is connected and secured with tape. An occlusive dressing covers the entry site and a gauze sponge is secured over the open end of the valve with a rubber band. In patients who have undergone resection and have a persistent air leak, a 16F anterior or axillary tube can be used, followed by removal of the larger drain(s) placed during the operation. More often, however, the valve is connected to the large lateral tube that already is in place, after shortening of its external length. For patients undergoing thoracoscopy, a 16F tube is placed through the most anterior of the working ports, usually at the anterior axillary line in the fourth or fifth intercostal space. A larger posterior drain, placed through a lower port and connected to underwater suction for 2 to 3 hours to evacuate fluid, is removed before hospital discharge. In all groups, most patients are discharged 2 to 6 hours after valve placement. Patients who have undergone resection occasionally are observed overnight. Patients are shown how the device functions, are given oral pain medication, and are assessed by physical examination and chest radiograph every 2 to 5 days. The timing of tube removal follows standard principles.


   Results
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
Outpatient chest tube management was used on 240 occasions in 214 patients. The numbers of episodes and patients are discordant because of instances of recurrent ipsilateral or metachronous contralateral pneumothorax. Table 1Go summarizes some of the data. Hospital admission for problems of tube placement or function was required in only 10 cases (4.2%). There were no deaths and no instances of serious infection or acute life-threatening pulmonary complications.


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  		Table 1. . Summary of 240 Cases of Outpatient Chest Tube Management
 
The pneumothorax group included 176 episodes in 150 patients and is reviewed in two categories. Most of the patients had primary spontaneous pneumothorax. The rest had pneumothorax of other causes. There were 96 instances of primary spontaneous pneumothorax in 81 patients. As expected for this diagnosis, the mean patient age was low and most of the patients were men (53 men and 28 women). The records document an ongoing air leak in 54 cases, note the absence of an air leak in 25, and fail to mention a persistent fistula in 17. Catheters placed for primary pneumothorax remained in place for a mean of 4.6 days. Although 8 patients required hospital admission with tubes still in place, only half the hospitalizations were necessitated by complications. The 4 failures included 2 immediate hospital admissions, 1 each for vertigo and reexpansion pulmonary edema, 1 admission for excessive pain the day after thoracostomy, and 1 admission for local infection at 1 week. The remainder were admitted for operation because of an uncomplicated persistent leak. Ambulatory tube management was used for 80 episodes of pneumothorax of causes other than primary spontaneous pneumothorax in 69 patients (37 men and 32 women). Their mean age of 55.3 years was higher by two decades than that of the primary spontaneous pneumothorax group. Causes included iatrogenic injury (39 patients), secondary spontaneous pneumothorax (25 patients), trauma (7 patients), catamenial pneumothorax (6 patients), tumor necrosis during chemotherapy (2 patients), and late postoperative collapse (1 patient). A persistent air leak was noted in 40 cases, was absent in 18, and was unspecified in 22. Chest tubes were removed between 1 and 19 days (mean, 4.9 days) after insertion. Of 7 patients in the secondary group who required hospital admission, 3 needed operation because of fistula persistence. The remaining 4 were failures, 1 with an acute vasovagal episode and 3 who required suction because of failure to maintain acceptable lung expansion.

The postoperative group included 45 patients with a persistent air leak (27 men and 18 women). They had undergone lobectomy (33 patients), wedge resection (10 patients), or unilateral bullectomy (2 patients), and they were discharged between 3 and 23 days (mean, 7.8 days) after operation. Their pleural drains were removed between 2 and 22 days (mean, 7.5 days) after hospital discharge. One patient who had undergone lobectomy was readmitted with pneumonia and parapneumonic effusion 2 weeks after hospital discharge.

Our initial experience with outpatient thoracoscopic pulmonary wedge resection includes 19 patients (12 men and 7 women) who underwent operation for pulmonary nodules (13 patients) or diffuse lung disease (6 patients). Their tubes were removed between 1 and 5 days (mean, 2.5 days) after operation. Although there were no air leaks at the time of hospital discharge, an air leak and considerable subcutaneous emphysema developed in 1 patient on the second postoperative day, and he was admitted for suction.


   Comment
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
The use of the Heimlich valve for the outpatient treatment of pneumothorax has been reported in the surgical literature. Mercier and associates [1] noted only one tube complication in 169 cases. In a series of 41 cases, Cannon and associates [2] successfully managed 88% of those that required thoracostomy without hospital admission. Nonetheless, hospital admission, large-bore tubes, and suction remain the standard approach in many institutions [4, 5]. Even those who favor small-bore catheters over traditional chest tubes as initial therapy report hospitalizing all [6–9] or most [10] of their patients.

Patients with primary spontaneous pneumothorax usually are ideal candidates for outpatient thoracostomy. Most are young and have normal lung function. Except in rare patients who have signs and symptoms of significant tension pneumothorax at presentation or hemopneumothorax from avulsed adhesions, acute life-threatening problems are not expected in this group, even with tube malfunction. We currently use ambulatory treatment for more than 90% of our patients who require chest tubes for primary pneumothorax. Patients with other types of pneumothorax are a more heterogeneous group, varying by cause and severity of their underlying disease. Those with significantly impaired pulmonary function should be admitted to the hospital. Most such cases are due to secondary spontaneous pneumothorax, mainly from emphysema, less commonly from interstitial disease, and increasingly from Pneumocystis carinii pneumonia. Many patients are profoundly symptomatic, have large air leaks, require additional drains for reexpansion, and are at risk of death due to temporary tube malfunction. Accordingly, about two thirds of our patients with secondary spontaneous pneumothorax were managed in the hospital. Iatrogenic pneumothorax from transthoracic needle biopsy often is suitable for outpatient care, because the pathology frequently is a localized neoplasm in patients with good pulmonary function. Catamenial pneumothorax occurs in young healthy women and generally can be handled without hospital admission. Traumatic pneumothorax occasionally results from minor blunt injury without rib fracture and can be considered for ambulatory thoracostomy.

In addition to patients with marginal pulmonary function, hospital admission is required for those who are unreliable, lack home support, or have excessive pain. Patients with significant residual pneumothorax and a high-volume air leak also should be observed in the hospital. The definitions of unacceptable residual collapse and worrisome air leak vary by patient. The important point is that the lung need not be reexpanded totally. We accept a small apical space because this common early finding does not presage later problems. On the other hand, when the postthoracostomy radiograph shows failure of apposition along most or all of the lateral chest wall, hospital admission is prudent. Between these extremes, judgments should be made on the basis of the patient's clinical status, the physician's satisfaction with the position of the tube, and the magnitude of the air leak. Hospitalization at presentation, however, need not continue until tube removal. Pain abates, air leaks decrease, and expansion often improves. Patients may be sent home at any time during their course. Those who require apicectomy for multiple recurrences can undergo outpatient thoracostomy and be admitted for operation after a few days or a weekend, for the convenience of both the patient and the surgeon.

Patients who have undergone pulmonary operations often are entirely stable and remain hospitalized solely because of an air leak. Rice and Kirby [11] reported peripheral fistulas that persisted for more than 7 days in 35 (15.2%) of 197 patients who underwent pulmonary resection. Only 3 patients (1.5%) still had an air leak at 2 weeks. Although there were no direct complications of prolonged parenchymal fistula, the postoperative hospital stay was 5.6 days longer in this group. McKenna and associates [3] described the use of the Heimlich valve to shorten the hospital stay for patients with postoperative air leaks. Twenty-five (24%) of 107 patients were discharged with valves in place 7 to 10 days (mean, 9.1 days) after a lung volume reduction operation. Forty percent had moderate or large air leaks and 64% had apical spaces measuring 1 to 7 cm (mean, 1.9 cm). All but 1 (96%) were managed successfully as outpatients and underwent tube removal between 2 and 24 days (mean, 7.9 days) after hospital discharge. Our experience confirms the feasibility of early hospital discharge in the setting of an uncomplicated air leak after a variety of pulmonary operations.

Video-assisted thoracoscopic wedge resection can be performed as an outpatient procedure. In most cases, there is no air leak. The volume of fluid drainage in our study usually was small, and it was evacuated by the temporary posterior tube in 2 to 3 hours. There were no instances of significant reaccumulation of pleural fluid. As for pneumothorax, patients who undergo thoracoscopic procedures often are much more comfortable on the first postoperative morning, and initial admission need not continue until tube removal. Indeed, it may be argued that these patients can be managed without drainage, because none of ours had an air leak immediately after the procedure. For the present, however, we believe that it is safer to leave a catheter in place, because an air leak developed in 1 patient after hospital discharge.

In addition to clinical safety and patient satisfaction, outpatient tube care saves money. Although the plethora of current financing arrangements renders exact comparisons difficult, the cost savings of outpatient versus inpatient treatment are obvious. In simpler times, Cannon and colleagues [2] noted a fivefold difference between ambulatory and hospital management of pneumothorax. In an earlier report, we calculated a differential of at least $3,000 per episode under the diagnosis-related group system [12]. In the present series, outpatient management saved approximately 1,263 inpatient days, a figure determined by the actual number of ambulatory days that tubes were in place for the pneumothorax and postresection groups and by assuming 1 hospital day for thoracoscopy. Estimates of overall savings must include, in addition to per diem cost, the extraneous laboratory, radiology, pharmacy, respiratory therapy, and miscellaneous charges that are generated universally for thoracic surgical cases in the inpatient setting.

In summary, the presence of a chest tube does not always require inpatient treatment. Ambulatory management often can be used to obviate or limit hospitalization. Requisites for success include patient education, careful attention to pain control, and accurate placement of a reliable drain. Standard 12F and 16F, 10-in.-long thoracic catheters, placed intracorporeally for most of their length, are easy to insert and maintain patency well. Outpatient management is applicable in the great majority of patients with primary spontaneous pneumothorax and in selected patients with secondary spontaneous and other types of pneumothorax. In addition, the use of the Heimlich valve may allow earlier hospital discharge after lung resection for stable patients with a prolonged air leak, and it makes outpatient thoracoscopy feasible in some cases.


   Footnotes
Top
 Footnotes
Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 
Address reprint requests to Dr Ponn, 330 Orchard St, New Haven, CT 06511.


   References
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

  1. Mercier C, Page A, Verdant A, Cossette R, Dontigny L, Pelletier LC. Outpatient management of intercostal tube drainage in spontaneous pneumothorax. Ann Thorac Surg 1976;22:163–5.[Abstract]
  2. Cannon WB, Mark JBD, Jamplis RW. Pneumothorax: a therapeutic update. Am J Surg 1981;142:26–9.[Medline]
  3. McKenna RJ, Fischel RJ, Brenner M, Gelb AF. Use of the Heimlich valve to shorten hospital stay after lung reduction surgery for emphysema. Ann Thorac Surg 1996;61:1115–7.[Abstract/Free Full Text]
  4. Paape K, Fry WA. Spontaneous pneumothorax. Chest Surg Clin N Am 1994;4:517–38.[Medline]
  5. O'Rourke JP, Yee ES. Civilian spontaneous pneumothorax: treatment options and long-term results. Chest 1989;96:1302–6.[Abstract/Free Full Text]
  6. Vallee P, Sullivan M, Richardson H, Bivins B, Tomlanovich M. Sequential treatment of a simple pneumothorax. Ann Emerg Med 1988;17:936–42.[Medline]
  7. Casola G, van Sonnenberg E, Keightly A, Ho M, Withers C, Lee AS. Pneumothorax: radiologic treatment with small catheters. Radiology 1988;166:89–91.[Abstract/Free Full Text]
  8. Conces DJ, Tarver RD, Gray WC, Pearcy EA. Treatment of pneumothoraces utilizing small caliber chest tubes. Chest 1988;94:55–7.[Abstract/Free Full Text]
  9. Perlmut LM, Braun SD, Newman GE, et al. Transthoracic needle aspiration: use of a small chest tube to treat pneumothorax. Am J Roentgenol 1987;148:849–51.[Abstract/Free Full Text]
  10. Martin T, Fontana G, Olak J, Ferguson M. Use of a pleural catheter for the management of simple pneumothorax. Chest 1996;110:1169–72.[Abstract/Free Full Text]
  11. Rice TW, Kirby TTJ. Prolonged air leak. Chest Surg Clin N Am 1992;2:803–11.
  12. Blank S, Ponn R, Stern H, et al. Outpatient treatment of uncomplicated pneumothorax. Conn Med 1988;52:199–200.[Medline]



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