Ann Thorac Surg 2007;84:630-632
© 2007 The Society of Thoracic Surgeons
New Technology
Postoperative Outpatient Chest Tube Management: Initial Experience With a New Portable System
Karen M. Rieger, MD*,
Heather A. Wroblewski, RN,
Jo Ann Brooks, DNS,
Zane T. Hammoud, MD,
Kenneth A. Kesler, MD
Thoracic Surgery Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
Accepted for publication February 5, 2007.
* Address correspondence to Dr Rieger, Indiana University School of Medicine, Department of Surgery, Thoracic Surgery Division, 545 Barnhill Dr, EH #215, Indianapolis, IN 46202 (Email: krieger{at}iupui.edu).
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Abstract
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Purpose: Prolonged air or fluid chest tube drainage may delay chest tube removal in thoracic surgery patients otherwise ready for discharge. We reviewed 20 months of experience at our institution with postoperative, outpatient chest tube management using a new portable chest tube device.
Description: From May 2003 to December 2004, 457 major thoracic procedures were performed at our institution. Besides excessive chest tube output or air leak, 50 patients met the criteria for discharge. There were 36 patients who were discharged with a new portable chest tube system (Express Mini 500; Atrium Medical Corp, Hudson, NH). Patients received written instructions and demonstrated competence on system use. Patients returned for chest tube removal after satisfactory resolution of air leak or fluid drainage.
Evaluation: Postoperative outpatient chest tube management accounted for 404 days. There were no major complications. Four patients experienced minor complications. Thirty-two patients (89%) experienced uneventful and successful outpatient chest tube management.
Conclusions: These data suggest that successful postoperative outpatient chest tube management can be accomplished in select patients. This program resulted in substantial hospital cost reduction and enhanced patient satisfaction by allowing earlier discharge.
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Technology
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Excessive fluid drainage or air leak through indwelling chest tubes (ChT) will occasionally prevent timely hospital discharge after thoracic surgery, which leads to increased length of stay associated with significant healthcare costs and potential patient dissatisfaction. In an attempt to facilitate hospital discharge in these cases, we implemented an outpatient chest tube program using a new portable ChT device.
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Technique
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Material and Methods
From May 2003 to December 2004, 457 major thoracic surgical procedures were performed at our institution. Besides excessive ChT fluid drainage (>100 cc/24 hours) or persistent alveolar air leak without pneumothorax on underwater seal, 50 patients met the criteria for discharge. These patients were further assessed for the following criteria: ability to follow instructions and understand written information about a new, portable ChT system (Express Mini 500 [Atrium Medical Corp, Hudson, NH]), determination of outpatient location within appropriate distance to medical support, and finally patient willingness to be discharged with a portable ChT system (Fig 1).
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Fig 1. The Express Mini 500 chest tube system (Atrium Medical Corp, Hudson, NH) is a small, lightweight, waterless device with a 500 cc fluid collection chamber. It has an air leak detection window with a dry one-way valve equivalent to a traditional underwater seal chamber. However, unlike an underwater seal chamber, it is not dependent on a stable horizontal position. Suction of 20 cm can be applied to the unit if needed. The chest tube system can be attached to the body by either the shoulder strap or belt hook that are provided, which facilitates ambulation.
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Clinical Experience
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Patients with marginal pulmonary function, excessive pain, high volume air leaks, or questionable reliability to follow instructions with no home support, or a combination thereof were not offered the outpatient ChT management. After this brief screening process, 36 patients (Table 1) were discharged with an outpatient ChT device, which was the basis of a retrospective review that was approved by our Institutional Review Board. Four of these patients (11%) had undergone surgical treatment of refractory pleural or pericardial effusions, and 32 patients (89%) underwent pulmonary, esophageal, or mediastinal resection. Twenty-eight patients (78%) either declined home-care assistance or home healthcare assistance could not be arranged, whereas 8 patients (22%) did have daily home-care nurse visits. Prior to discharge these patients demonstrated competence on system use that included ChT site dressing changes, emptying and recording daily fluid output from the collection chamber (n = 31), or observation for resolution of air leak (n = 5). After 1 patient experienced an inadvertent chest tube disconnection with an asymptomatic pneumothorax early in this program, plastic banding ties (Gish Biomedical, Santa Ana, CA) were used to secure all connections to the system before discharge, which eliminated this problem. All patients were contacted by a nurse practitioner either routinely or on an as needed basis. Patients received emergency contact information and were instructed to contact the thoracic surgery clinical nurse coordinator for questions or arrangement for ChT removal, or both, when drainage <100 cc/24 hours or air leak after forceful cough had subsided.
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Results
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Postoperative outpatient ChT management accounted for a total of 404 days (mean, 11.2 ± 8.1 days/patient; range, 3 to 36 days). Patients discharged with alveolar air leak had a longer duration of outpatient ChT management (mean, 17.2 ± 11.2 days/patient; range, 8 to 36 days) as compared with patients discharged with excessive fluid drainage (mean, 10.3 ± 7.3 days/patient; range, 3 to 34 days). Outpatient ChT management during this time period saved more than $262,000 in hospital charges (number of outpatient ChT days x $650/day general unit room charge). Figure 2
illustrates both the length of hospital stay (mean, 10.4 ± 4.5 days/patient) and duration of outpatient ChT management of patients in this series.
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Fig 2. Graph depicting individual patient data (n = 36) for hospital length of stay and outpatient chest tube drainage. (ChT = chest tube.)
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Overall, 32 patients (89%) experienced uneventful and successful outpatient ChT management. There were no major or life threatening complications. No patients experienced complications as a result of system malfunction. Four patients (11%) experienced minor complications. As previously stated, 1 patient experienced a pneumothorax requiring brief rehospitalization for application of suction to the unit after tube disconnection early in the series. One patient was discharged with an alveolar air leak after a lobectomy developed a localized empyema on postoperative day 17 (ie, outpatient day 8), which was successfully treated by percutaneous drainage and intravenous antibiotics. One patient was briefly readmitted for pain control and another was treated as an outpatient for cellulitis at the ChT-skin site. Although not considered a complication of the outpatient ChT program per se, a patient with a prolonged alveolar air leak after pulmonary resection required pleurodesis with talc slurry through the indwelling chest tube for failure to demonstrate resolution on postoperative day 55 (outpatient day 25). Finally, all patients in this series reported good to excellent mobility with this device and were appreciative of early hospital discharge.
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Comment
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Although patients have traditionally remained hospitalized until satisfactory resolution of either excessive ChT fluid or alveolar air leak after thoracic surgical procedures, during the past decade, third-party payers have pressured earlier discharge or increased use of outpatient care, or both. Cerfolio and colleagues [1] have recently proposed "fast tracking" of thoracic surgical patients with ChT removal when fluid drainage was less than 400 cc daily, which usually occurred by the second postoperative day. In this large series, no patient required thoracentesis or ChT replacement for symptomatic effusion using this algorithm. Our criteria of 100 cc daily prior to ChT removal may be considered conservative; however, this is based on observations from our institution to allow significantly greater amounts of fluid drainage at the time of tube removal that will not infrequently result in recurrent symptomatic effusions and the need for either thoracentesis or ChT replacement, particularly after extensive mediastinal dissection.
Approximately 15% of patients who have undergone pulmonary operations remain hospitalized solely because of alveolar air leak [2]. Connecting a Heimlich valve to a urinary collection bag has been the traditional method to establish an outpatient drainage system in these cases [3]. McKenna and associates [4] described the use of the Heimlich valve to shorten the hospital stay for 25 patients demonstrating postoperative air leaks after lung volume reduction surgery with 96% success. Ponn and colleagues [5] similarly reported use of an outpatient Heimlich valve for post-pulmonary resection air leaks in 45 patients with a 98% success rate. However, fibrinous drainage can obstruct either the afferent or efferent Heimlich ports. Moreover, there exists potential for an ascending pleural space infection through this "open" type of drainage system. Other devices have been reported for the treatment of parenchymal air leak on an outpatient basis; However, to date, these devices are not designed to manage fluid drainage, cannot be connected to active suction, are not widely available, or a combination thereof [6–8].
Until more precise criteria for ChT removal are established, which takes not only quantitative fluid or air drainage, but specific operative and patient demographic variables into consideration, we believe a conservative approach will minimize recurrent effusions or pneumothorax after premature ChT removal. This strategy includes the use of a comprehensive outpatient ChT program. With more aggressive surgical approaches being used in the treatment of solid intrathoracic malignancies, we furthermore believe that an increasing number of patients will be appropriately managed in the outpatient setting with closed ChT drainage systems. These data demonstrate promising preliminary results using a novel ChT drainage device for the outpatient management of select patients with excessive fluid or air leaks after a variety of thoracic surgical procedures. Not only does this program result in substantial hospital cost reduction, but it also enhances patient satisfaction by allowing earlier discharge.
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Disclosures and Freedom of Investigation
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This study was funded completely through the Department of Thoracic Surgery. No financial relationship exists between any of the authors and Atrium Medical Corp.
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Disclaimer
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The Society of Thoracic Surgeons, the Southern Thoracic Surgical Association, and The Annals of Thoracic Surgery neither endorse nor discourage use of the new technology described in this article.
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References
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- Cerfolio RJ, Pickens A, Bass C, Katholi C. Fast-tracking pulmonary resections J Thorac Cardiovasc Surg 2001;122:318-324.[Abstract/Free Full Text]
- Rice TW, Kirby TJ. Prolonged air leak Chest Surg Clin N Am 1992;2:803-811.
- Heimlich HJ. Valve drainage of the pleural cavity Dis Chest 1968;53:283-287.
- McKenna RJ, Fischel RJ, Brenner M, Gelb AF. Use of the heimlich valve to shorten hospital stay after lung reduction surgery for emphysema Ann Thor Surg 1996;61:1115-1117.[Abstract/Free Full Text]
- Ponn RB, Silverman HJ, Federico JA. Outpatient chest tube management Ann Thorac Surg 1997;64:1437-1440.[Abstract/Free Full Text]
- Samelson SL, Goldberg EM, Ferguson MK. The thoracic vent: clinical experience with a new device for treating simple pneumothorax Chest 1991;100:880-882.[Medline]
- Lodi R, Stefani A. A new portable chest drainage device Ann Thor Surg 2000;69:998-1001.[Abstract/Free Full Text]
- McManus KG, Spence GM, McGuigan JA. Outpatient chest tubes Ann Thorac Surg 1998;66:299-300.[Free Full Text]
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