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Communications to the Editor |

PneumothoraxPneumothorax: Is Chest Tube Clamp Necessary Before Removal? FREE TO VIEW

Neeraj Gupta, MD
Author and Funding Information

Affiliations: Ajmer, India,  E Wolfson Medical Center Holon, Israel

Correspondence to: Neeraj Gupta, MD, Government Doctors Quarters, Type III, Opposite Fire Station, Near Ajmer Club, Ajmer - 305001, (Rajasthan) India; e-mail: guptang@yahoo.com



Chest. 2001;119(4):1292-1293. doi:10.1378/chest.119.4.1292
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Published online

I read with interest the study, “Pneumothorax: Experience With 1,199 Patients” (May 2000).1 While the discussion part of the article was thorough and informative, the statement that the pleural drain should be removed without clamping after the cessation of air leak needs further exploration. As the choice of therapeutic procedure varies according to the number of episodes, the size of pneumothorax, and the particular group of investigators, chest tube removal should also be dependent on the underlying lung disease, the presence or absence of bronchopleural fistula, the history of pneumothorax, and the severity of the initial episode.

Primary spontaneous pneumothorax has been viewed as low-mortality nuisance.2 Chest tubes may be removed as soon as the lung expands and air leak ceases. In the presence of underlying lung disease or when pneumothorax has been associated with bronchopleural fistula, it is always imperative to clamp the tube for a variable duration before it is removed.

Many physicians also agree that the chest tube should be clamped before it is finally removed.36 Similar is the recommendation in the Light textbook on pleural diseases.7An analysis on pneumothorax management performed by Baumann and Strange8 also verifies the above view, where at least 67% of the responders suggested chest tube clamping for a period varying from 4 to 24 h. Another 27% in their study preferred to wait for at least 24 h after the air leak stopped before the chest tube was removed, although they did not prefer a clamp. Similar was the authors’ approach in the present study,1 but they ultimately suggested not to wait or clamp the tube.

In my experience, it is not uncommon to observe a relapse of pneumothorax after removal of chest tube as soon as the lung expands or air leak ceases. I would also like to mention an Indian study9 performed by my senior colleagues, in which they observed that the early removal (6 h) of the chest tube after complete expansion of the lung results in a greater relapse rate than removal after 48 h.

The onset of breathlessness at a variable time after a clamp would definitely indicate more prolonged chest tube drainage. The discomfort caused by such a clamp for 24 h would be lesser than a second chest tube insertion after relapse. If the chest tube was not working (no water column movement and no air leak) overnight, then it may be considered as good as a clamp, and it may be removed if the lung is completely expanded clinically and radiologically. In my opinion, a clamp for 12 to 24 h before removal of the drain is one aspect of authors’ view of patience in the management of pneumothorax.

How could a chest tube be dangerous in a patient with a possible tension pneumothorax? Once the chest tube is clamped and if the patient suddenly develops breathlessness, the only thing to do is to remove the clamp and observe the vital parameters closely. In fact, for the case of a clamped chest tube, the patient and duty staff should be asked about the measures to be taken as soon as breathlessness precipitates. If the symptoms of tension pneumothorax may develop after a clamp, then why not on removal of the chest drain? This point needs further clarification.

Weissberg, D, Refaely, Y (2000) Pneumothorax: experience with 1,199 patients.Chest117,1279-1285. [CrossRef] [PubMed]
 
Baumann, MH, Strange, C Treatment of spontaneous pneumothorax: a more aggressive approach?Chest1997;112,789-804. [CrossRef] [PubMed]
 
Andrivet, P, Djedaini, K, Teboul, JL, et al Spontaneous pneumothorax: comparison of chest drainage vs immediate or delayed needle aspiration.Chest1995;108,335-339. [CrossRef] [PubMed]
 
Schoenenberger, RA, Haefeli, WE, Weiss, P, et al Timing of invasive procedures in therapy for primary and secondary spontaneous pneumothorax.Arch Surg1991;126,764-766. [CrossRef] [PubMed]
 
Schoenenberger, RA, Haefeli, WE, Weiss, P, et al Evaluation of conventional chest tube therapy for iatrogenic pneumothorax.Chest1993;104,1770-1772. [CrossRef] [PubMed]
 
So, S, Yu, D Catheter drainage of spontaneous pneumothorax: suction or no suction, early or late removal?Thorax1982;37,46-48. [CrossRef] [PubMed]
 
Light, RW Pleural diseases 3rd ed.1995,242-277 Williams & Wilkins. Baltimore, MD:
 
Baumann, MH, Strange, C The clinician’s perspective on pneumothorax management.Chest1997;112,822-828. [CrossRef] [PubMed]
 
Sharma, TN, Agnihotri, SP, Jain, NK, et al Intercostal tube thoracostomy in pneumothorax.Indian J Chest Dis Allied Sci1988;30,32-35. [PubMed]
 
To the Editor:

I appreciated the opportunity to read the comments of Dr. Gupta on our report (May 2000) on pneumothorax.1Dr. Gupta objected to our policy of removing the pleural drain without clamping it for a number of hours. Also, he implied incorrectly that we remove the drain immediately after the drainage stops, without waiting for 24 h. In support of his preference to clamp the tube, he quoted several authors who favor clamping. With your permission, I would like to quote some others, who do not clamp.6 However, this controversy cannot be solved by a democratic referendum. The decision “to clamp or not to clamp” must be clinically sound and based on experience, not on voting. There is no logic in clamping a tube that has not drained anything for a number of hours. When drainage stops, we leave the drain for 24 h prior to removal. However, as a clamped tube serves no purpose, it should be left unclamped. While some pulmonologists and thoracic surgeons may be in favor of clamping, there is no scientific evidence to support it.

References
Weissberg, D, Refaely, Y Pneumothorax: experience with 1,199 patients.Chest2000;117,1279-1285. [CrossRef] [PubMed]
 
Belcher, JR, Sturridge, MF Thoracic surgical management 4th ed.1972,154-158 Bailliere Tindall. London, UK:
 
von Hippel, A A manual of thoracic surgery1978,112 Charles C. Thomas. Springfield, IL:
 
Gregoire, J, Deslauriers, J Closed drainage and suction systems. Pearson, FG Deslauriers, J Ginsberg, RJet al eds.Thoracic surgery1995,1126 Churchill Livingstone. New York, NY:
 
Martin, T, Fontana, G, Olak, J, et al Use of a pleural catheter for the management of simple pneumothorax.Chest1996;110,1169-1172. [CrossRef] [PubMed]
 
Hatz, RA, Kaps, MF, Meimarakis, G, et al Long-term results after video-assisted thoracoscopic surgery for first-time and recurrent spontaneous pneumothorax.Ann Thorac Surg2000;70,253-257. [CrossRef] [PubMed]
 

Figures

Tables

References

Weissberg, D, Refaely, Y (2000) Pneumothorax: experience with 1,199 patients.Chest117,1279-1285. [CrossRef] [PubMed]
 
Baumann, MH, Strange, C Treatment of spontaneous pneumothorax: a more aggressive approach?Chest1997;112,789-804. [CrossRef] [PubMed]
 
Andrivet, P, Djedaini, K, Teboul, JL, et al Spontaneous pneumothorax: comparison of chest drainage vs immediate or delayed needle aspiration.Chest1995;108,335-339. [CrossRef] [PubMed]
 
Schoenenberger, RA, Haefeli, WE, Weiss, P, et al Timing of invasive procedures in therapy for primary and secondary spontaneous pneumothorax.Arch Surg1991;126,764-766. [CrossRef] [PubMed]
 
Schoenenberger, RA, Haefeli, WE, Weiss, P, et al Evaluation of conventional chest tube therapy for iatrogenic pneumothorax.Chest1993;104,1770-1772. [CrossRef] [PubMed]
 
So, S, Yu, D Catheter drainage of spontaneous pneumothorax: suction or no suction, early or late removal?Thorax1982;37,46-48. [CrossRef] [PubMed]
 
Light, RW Pleural diseases 3rd ed.1995,242-277 Williams & Wilkins. Baltimore, MD:
 
Baumann, MH, Strange, C The clinician’s perspective on pneumothorax management.Chest1997;112,822-828. [CrossRef] [PubMed]
 
Sharma, TN, Agnihotri, SP, Jain, NK, et al Intercostal tube thoracostomy in pneumothorax.Indian J Chest Dis Allied Sci1988;30,32-35. [PubMed]
 
Weissberg, D, Refaely, Y Pneumothorax: experience with 1,199 patients.Chest2000;117,1279-1285. [CrossRef] [PubMed]
 
Belcher, JR, Sturridge, MF Thoracic surgical management 4th ed.1972,154-158 Bailliere Tindall. London, UK:
 
von Hippel, A A manual of thoracic surgery1978,112 Charles C. Thomas. Springfield, IL:
 
Gregoire, J, Deslauriers, J Closed drainage and suction systems. Pearson, FG Deslauriers, J Ginsberg, RJet al eds.Thoracic surgery1995,1126 Churchill Livingstone. New York, NY:
 
Martin, T, Fontana, G, Olak, J, et al Use of a pleural catheter for the management of simple pneumothorax.Chest1996;110,1169-1172. [CrossRef] [PubMed]
 
Hatz, RA, Kaps, MF, Meimarakis, G, et al Long-term results after video-assisted thoracoscopic surgery for first-time and recurrent spontaneous pneumothorax.Ann Thorac Surg2000;70,253-257. [CrossRef] [PubMed]
 
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