Pulling Chest Tube on Vent

[slycaper]

I am not ******ed, I would not pull a chest tube in a vented patient. However if there is no air leak it seems physiologically speaking it would be possible. Anyone hear of someone pulling a chest tube on a vented patient?

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[Doctor Bob]

Sure; some of our post-trauma patients live on vents for months but their lung problems improve much faster. So we pull the tube. Worst case, we put a new one in. Doesn't happen that often.

 

[jdh71]

Sure; some of our post-trauma patients live on vents for months but their lung problems improve much faster. So we pull the tube. Worst case, we put a new one in. Doesn't happen that often.

Yeah. I've seen the surgeons do this in patients where the reason for the pneumo was secondary to something that wasn't actually the lungs (ie intrinsic medical pathology of the lungs).

In the MICU though, if you get a pneumo, it's almost entirely because your lungs went ******ed and that tube is in until you you're back to negative pressure ventilation. I have seen a few tubes gets pulled or fall out with only the need for ONE emergent tube out of an n= 5 or 6, so it's probably okish even the MICU population if you really need to and have a good reason, still . . . I don't plan to take them out regularly in this situation.

 

[ORL10]

How many of you put the chest tube to water seal in post-op patients with a continued air leak. For whatever reason our surgical department isn't excited about taking the CT off suction with an air leak. Seems to me that a BPF may resolve more quickly if on waterseal >> suction.

 

[jdh71]

How many of you put the chest tube to water seal in post-op patients with a continued air leak. For whatever reason our surgical department isn't excited about taking the CT off suction with an air leak. Seems to me that a BPF may resolve more quickly if on waterseal >> suction.

Do you mean post-op on the vent? Or just post-op chest tube?

 

[europeman]

Depends why it went in. If it's a tube for a pneumo from a central line error.... After couple days it will deal/heal.

I'm a trauma surgeon: in trauma we routinely pull chest tubes on vented patients.

If you have concern.... You can always clamp the chest tube (ie pseudo-pull) and check x ray in several hours. If it's okay you are more confident pulling it won't be problematic.

I personably pull chest tubes pretty quickly. Like anything they have morbidity. Worst thing happens is you have to replace it

 

[Hamhock]

I am not ******ed, I would not pull a chest tube in a vented patient. However if there is no air leak it seems physiologically speaking it would be possible. Anyone hear of someone pulling a chest tube on a vented patient?

[Maybe] I am [not] ******ed,...I have pulled plenty of chest tubes (in my relatively short career) form patients still on the vent. I have yet to see a tension PTX from it.
HH

 

[jdh71]

Heh.

We all haven't seen anything, until . . . we do . . .

 

[ORL10]

Im saying you have a non-intubated post-op thoracic patient who has a continued air leak and has been on wall suction which if there is a BPF the suction is keeping it open.

Really this could apply to anyone, say a trauma patient with an air leak on suction, but no PTX on cxr. Why not go to water seal, despite the air leak, this way you are no longer creating a negative intraplueral pressure and stenting open that BPF, and potentially the air leak will cease sooner?

Yes you can clamp it, but I'm saying you aren't ready to pull the tube because of an air leak, you are on suction for the last couple of days, why not switch over to water seal despite the continued leak? A tension cannot develop because you still have a tube in the pleural space and any positive pressure that develops will come out (assuming a non-kinked properly placed CT) via the water seal.

 

[europeman]

I agree never clamp tube with leak!

 

[dpmd]

Im saying you have a non-intubated post-op thoracic patient who has a continued air leak and has been on wall suction which if there is a BPF the suction is keeping it open.

Really this could apply to anyone, say a trauma patient with an air leak on suction, but no PTX on cxr. Why not go to water seal, despite the air leak, this way you are no longer creating a negative intraplueral pressure and stenting open that BPF, and potentially the air leak will cease sooner?

Yes you can clamp it, but I'm saying you aren't ready to pull the tube because of an air leak, you are on suction for the last couple of days, why not switch over to water seal despite the continued leak? A tension cannot develop because you still have a tube in the pleural space and any positive pressure that develops will come out (assuming a non-kinked properly placed CT) via the water seal.

A lot of time they would do better on water seal (assuming the lung is up), but a lot of what people do is based on the voodoo you were taught rather than current literature.

 

[jdh71]

Im saying you have a non-intubated post-op thoracic patient who has a continued air leak and has been on wall suction which if there is a BPF the suction is keeping it open.

Really this could apply to anyone, say a trauma patient with an air leak on suction, but no PTX on cxr. Why not go to water seal, despite the air leak, this way you are no longer creating a negative intraplueral pressure and stenting open that BPF, and potentially the air leak will cease sooner?

Yes you can clamp it, but I'm saying you aren't ready to pull the tube because of an air leak, you are on suction for the last couple of days, why not switch over to water seal despite the continued leak? A tension cannot develop because you still have a tube in the pleural space and any positive pressure that develops will come out (assuming a non-kinked properly placed CT) via the water seal.

There is nothing wrong with water seal in the situation you are asking about.

You like to make sure the lung is up first, as having the pleural surfaces together promotes healing and gives you comfort that your tube is in the right position to do the job. Once you've got the lung up on suction, moving to water seal is the next step even if there still is an air leak. Get a film after a bit and if the lung us up, leave it to water deal and wait for the leak to stop.

 

[ThoracicGuy]

How many of you put the chest tube to water seal in post-op patients with a continued air leak. For whatever reason our surgical department isn't excited about taking the CT off suction with an air leak. Seems to me that a BPF may resolve more quickly if on waterseal >> suction.

I always want to get my patients to water seal as soon as I can. I don't care if there is a leak. The only way I would go back to suction is if the lung drops on seal.

 

[Hernandez]

If you're nervous, clamp it for a day. Bad lung pts tend not to come out, but for other reasons come out easily

 

[ORL10]

ok so this nonsense at my shop of keeping on suction until the leak is gone (even if its a small leak) is out of habit not practiced most other places? i did a lit search there is amazingly little data on this small 60 person rct in chest 10 years ago ( meta-analysis with 600 pts?)and some retrospective stuff with expert opinion. seems physiologically water seal would be superior for most leaks and get the tube out faster after early suction immediately post-op/placement.

 

[Dwindlin]

We keep them on suction forever here too. Though I think my own practice will mirror the majority of those here.


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[dpmd]

ok so this nonsense at my shop of keeping on suction until the leak is gone (even if its a small leak) is out of habit not practiced most other places? i did a lit search there is amazingly little data on this small 60 person rct in chest 10 years ago ( meta-analysis with 600 pts?)and some retrospective stuff with expert opinion. seems physiologically water seal would be superior for most leaks and get the tube out faster after early suction immediately post-op/placement.

I wouldn't say the way they do it at your place is uncommon at all.

 

[nlax30]

Same here, our surgeons keep them on suction.

 

[neusu]

We take them out routinely, put them to water seal first. If there is a pneumo we don't take them out, if not, then yes. Can always put back in if it's necassary.