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a Section of Thoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
b Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
Accepted for publication April 1, 2011.
* Address correspondence to Dr Cerfolio, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, 703 19th St S, ZRB 739, Birmingham, AL 35294 (Email: rcerfolio{at}uab.edu).
Presented at the Poster Session of the Forty-seventh Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31–Feb 2, 2011.
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Abstract |
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Methods: Patients underwent thoracotomy and pulmonary resection, and all had a daily CXR. The impact the CXR had on their care was evaluated. Hypoxia was defined as a sustained decrease in oxygen saturation of 6% or greater from patient's baseline.
Results: Between January 2006 and December 2009, 1,037 patients met the eligibility criteria for this study. Types of resection were wedge in 282 patients, segmentectomy in 146, and lobectomy in 609. Only 20 of the 834 patients (2%) who did not have a pneumothorax on the recovery room CXR had hypoxia, compared with 42 patients (21%) who had a recovery room pneumothorax (odds ratio 10.6, 95% confidence interval: 6.1 to 18.5, p < 0.001). Daily CXR changed the care of only 268 of 975 patients (27%) who never had hypoxia compared with 49 of the 62 patients (79%) who were hypoxic (odds ratio 9.2, 95% confidence interval: 4.3 to 13.7, p < 0.001). Moreover, the changes in care made by the CXR in the 268 nonhypoxic patients were for small pneumothoraces, and the impact of these changes is dubious.
Conclusions: Daily CXRs are not needed in the vast majority of patients who undergo elective pulmonary resection after thoracotomy. It is of little benefit for patients who do not have a pneumothorax on their recovery room CXR or for patients who do not become hypoxic.
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Introduction |
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| Dr Cerfolio discloses that he has financial relationships with E plus health care, Ethicon, Neomend, Medela, Closure/J&J, OSI Pharm, Atrium, Caris, Covidien, Precision, and Intuitive.
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The use of daily chest roentgenography for patients who have undergone pulmonary resection is common place. In fact, some believe that a chest tube is an absolute indication for a chest roentgenogram (CXR). Even though there are scant data to support this opinion, it is the current practice at most institutions. Over the past several years, many studies have challenged some of the surgical dogma of thoracic surgery and of the postoperative care of patients who have undergone pulmonary resection [1]. This study examines the clinical impact that a daily CXR has on patient care after elective pulmonary resection.
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Material and Methods |
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19 years, underwent elective open thoracotomy by one general thoracic surgeon and who went to the floor postoperatively were eligible for this study. Patients who underwent pneumonectomy, had a video-assisted thoracoscopic or robotic approach used for pulmonary resection or went to an intensive care unit were excluded from this study. The University of Alabama at Birmingham's Institutional Review Board approved this protocol (X091201012) as well as the prospective database (X030403013) used to collect information for this study. Patient consent was waived for inclusion in this individual study; however, it was required and obtained to enter patient data in the prospective database.
Patients underwent pulmonary resection in our practice based on criterion we have previously defined [2]. At the completion of the operation, one soft 28F chest tube (Deknatel, Jaffrey, NH) was placed posteriorly and in the apex. The tubes were placed to –20 cm water of active wall suction in the operating room during closure and were kept on this setting once the patient arrived in the recovery room. A portable CXR was performed in the recovery room. The film was read by one of five board-certified thoracic radiologists, and only that reading was used for this study. The film was recorded in this study as having a pneumothorax or not. However, and importantly in this study, CXRs that showed a small apical pneumothorax that were less than one rib space and that had no lateral component were considered as not having a pneumothorax; all others were labeled as having a pneumothorax.
Chest tubes were placed to water seal on the morning of postoperative day 1. The absence or presence of a pneumothorax was recorded. Hypoxia was defined as having any one or more of the following: a consistent decrease in oxygen saturation of 6% or greater; and new or expanding subcutaneous emphysema was recorded as palpable, new, or expanding, or radiologically apparent only, and was an indication to place a chest tube to active wall suction from water seal. Patients were labeled hypoxic or not hypoxic.
Daily CXRs were performed in the evening for all patients every day. Patients were transported to the radiology department between 7 PM and 10 PM, and a posteroanterior and lateral film was obtained. These films were considered the next morning's film to allow the patients to sleep. These films were read by one of five board-certified thoracic radiologists, and only the official radiologist's reading of the CXR was used for this study. The endpoint of this study was a change in any patient's management attributed to the daily CXR findings.
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Results |
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Table 2 provides information on the CXR findings and how it affected patient care. Most of the management changes in these 268 nonhypoxic patients were minor (eg, increasing the suction on chest tubes for patients with increasing but asymptomatic pneumothoraces). In 49 of the 62 hypoxic patients, changes were made as noted. The remaining 13 patients had an essentially normal CXR. Their causes of hypoxia were thought to be pulmonary emboli in 5 patients and severe bronchospasm in 8; however, either empiric antibiotics or diuretic therapy was added in all cases. Table 2 also depicts the large number of patients who had changes made based on the CXR findings who were not symptomatic. The impact that these changes had on their care is dubious. The most common day that the CXR led to changes was on postoperative day 2, and the most common pulmonary resection that led to a change because of the CXR was lobectomy.
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Comment |
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In this study, we have shown that the vast majority of patients who underwent pulmonary resection through thoracotomy who had no pneumothorax on their recovery room film and were not hypoxic did not benefit from a daily CXR. It is important to note that this conclusion is independent of air leak status. In this study, to deliver a simple, clear, and concise message from the study, we intentionally did not include the presence or size of an air leak. When air leak status (ie, hypoxic patients with a big air leak and no pneumothorax, hypoxic patients with a small air leak and no pneumothorax, and so forth) is included in the analysis, it confounded the results of this study. The main import of these data is that the care of few patients is significantly changed by performing a daily portable CXR unless they are hypoxic, irrespective of their air leak status. However, because a significant air leak is a surrogate marker for a pneumothorax on the recovery room CXR, as is subcutaneous emphysema, we elected to study these endpoints and not air leak status as most surgeons do not size the daily air leak status anyhow.
Additionally, we excluded patients who underwent video-assisted thoracoscopic or robotic pulmonary resection to ensure that the patient population was as homogeneous as possible; however, there is no reason in our experience to think that these findings are not translatable to these patients as well. We also excluded patients who underwent pneumonectomy, because hypoxia in a postpneumonectomy patient is often for different reasons when compared with patients who have had a lobar or sublobar resection. We favor a daily standing CXR of these patients to observe a rising fluid collection in the pneumonectomized space and to ensure the lack of abnormalities in the remaining lung.
The cost of a daily morning CXR and the inconvenience to the patient are both underestimated. A portable CXR usually entails waking patients at very early hours and disrupts their already limited sleep. Furthermore, a portable CXR is performed by placing a cold and hard metal plate under the patient's back; there is also the cost of paying a radiology technician (who at our institution makes approximately $20 an hour) and the radiologist to interpret the film (approximately $50). Hence, we changed our postoperative algorithm to obtaining daily CXRs in the evening in the department; moreover, they are of much better quality than a portable CXR and allow the patients to better sleep through the night. It also has saved our institution money.
Our recommendation based on these data is clear. If a patient is hypoxic or has new or enlarging subcutaneous emphysema or an enlarging pneumothorax on a previous CXR, subsequent CXRs should be performed after chest tube settings are changed. If there are other important clinical changes (a fever, increasing white blood cell count, and so forth), a CXR may be beneficial. However, for the asymptomatic patient, we found no evidence that the daily CXR led to any important clinical management change. Even though 27% of these patients had some minor changes made in their chest tube settings (namely, we increased the suction), there was not significant effect from these changes, and thus we cannot support a daily CXR for these patients.
The strengths of this study are that all CXRs were read by a board-certified chest radiologist; they were performed in the department as posterior-anterior and lateral films and not as portable films; one surgeon performed all the operations and used the same type, size, and placement of the chest tube; and a consistent definition of hypoxia was used throughout this study. It also was performed on a homogenous group of patients. However, the limitations of this study are that more than one radiologist read the CXR films, the quality of the CXR films varied, and subcutaneous emphysema can obscure a pneumothorax.
In conclusion, we have shown that daily CXRs are not needed for the vast majority of patients who undergo elective pulmonary resection after thoracotomy and are on the floor. This finding is similar to that of previous studies that examined patients in the intensive care unit. Our study also shows that daily CXRs are of little benefit for patients who do not have a pneumothorax on their recovery room CXR and for patients who do not become hypoxic during their hospital stay. Finally, there are no data to suggest that a daily CXR of asymptomatic patients who are doing well after elective pulmonary resection adds any clinically relevant or important aspect to the patients' care. Therefore, we no longer recommend their use.
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