How safe is it to discharge home patients with a chest tube in place? A narrative review of the literature

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INTRODUCTION

Postoperative persistent air leak (PAL, defined as an air leak lasting longer than 5 days after lung surgery or following insertion of a thoracic drain due to a pneumothorax) and excessive fluid drainage are among the most common conditions contributing to prolonged hospital length of stay (LOS) in patients undergoing lung resections or being treated for pneumothorax [1–5].

In patients undergoing lung resection, the reported percentage of a prolonged LOS due to postoperative air leak is between 6% and 28% [2, 3].

The delay in chest tube removal is associated with several potential complications such as atelectasis, pneumonia, empyema, redo surgery and increased hospital costs [4–6].

Many attempts have been made to identify significant risk factors for prolonged air leak. While factors such as reduced pulmonary function, previous adhesions, use of steroids, upper lobectomy, complex segmentectomy, age, low body mass index and others were found to be associated with prolonged air leak, at the current time, there is no sustainable model that could accurately predict neither the development nor the duration of an air leak [7, 8].

The increasing focus on quality measurements, along with the effort of hospital costs containment while maintaining quality of patient care, led over the last several years to the development of practice to discharge patients home with chest tube in situ [4–6, 9].

Nevertheless, there are still many concerns about the outpatient setting for these patients, mainly due to the lack of internationally recognized recommendations and due to morbidity associated with prolonged chest tube duration [4, 9–11]. This article aims to review the current literature on this topic and to provide an overview of management and outcomes of patients discharged home with chest tube in situ after lung resection or chest drain insertion.

DISCHARGE AFTER LUNG RESECTION

The 1st report of outpatient management with chest tube in situ was published in 1996 by McKenna and colleagues [12]. In their retrospective study, they reported a 23.4% rate of patients with PAL 5 days after lung volume reduction surgery. Using a Heimlich valve, the authors were able to reduce the postoperative LOS by 46%. Of 25 patients discharged with a chest tube, only 1 was readmitted due to subcutaneous emphysema, no other complications were observed.

Similarly, Ponn et al. reported the usage of Heimlich valve on 45 patients who underwent lung surgery with a 98% of success rate and reduction of hospital costs [13].

Cerfolio and his group discharged 33 patients with a chest tube on Heimlich valve and they did not observe any complications stating that it seems to be a safe and effective management that allows patients to go home with PAL. No empyema was observed in this series. Notably, all the patients with chest tube in place received antibiotics [14].

Rieger and colleagues reported an outpatient management with digital mini-Atrium device in 36 patients with PAL or excessive effusion after lung resection. About 89% of patients had an uneventful course and 11% experienced minor complications (3 patients were readmitted, 1 of which was for an empyema). Central point for this trial was the identification of the suitable sub-population for the outpatient setting with inclusion criteria such as: appropriate distance to medical support, reasonable control of pain, no marginal pulmonary function and good patient’s compliance [15].

A cost analysis from Leeds was published in 2012 showing that nurse-led clinics, created to manage and follow-up outpatients with chest tube, led to an extra income of €24 899 for the department by reducing the staffing costs. Complications related to prolonged chest tube drainage were observed in 18% of the patients. Six suffered from a superficial infection of the chest tube site and received only oral antibiotics without need for further interventions; in 4 patients, a residual air space was detected once the chest tube was removed (1 required additional chest drain insertion); 3 patients developed an empyema [16].

Similarly, a modest cost reduction ($686.72 per patient, $50 130.67 total) was reported in a cohort of 73 patients discharged with chest tube due to PAL post-lobectomy with minor complications observed in 2.7% of cases. A comparison with a control group, namely patients who underwent lobectomy and were managed without outpatient setting, showed no statistically significant difference in 30-day readmission rate (11.7% vs 9.0%, P = 0.615) [17].

The safety of discharging patients with a chest tube was questioned in 2 papers published in 2018 and 2021, respectively. The 1st, a single-centre retrospective analysis from the Mayo Clinic, showed that the outpatient setting is not without consequences, with a readmission rate of 26.3% and empyema occurring in 16.9% [9]. Similar results have been reported from our group in a multicentre analysis that analysed 253 patients discharged with chest tubes due to PAL after pulmonary resections in 4 institutions. The observed readmission rate was 19.4% (n = 49) with an empyema in 18 readmitted patients (of those, 11, namely 61%, required a redo surgery). A locally weighted scatterplot smoothing (LOWESS) analysis showed that empyema rate increased nearly 3-fold in odds when the chest tube remained in situ for more than 20 days, rising to 20% at 35 days and to 50% at 80 days [4].

Dinjens et al. reported an uncomplicated ambulatory treatment in 75 of 81 patients (93%) after pulmonary resection and in 37 of 59 patients (63%) in the pneumothorax group. Readmission rate was 23.6% with 10% of patients suffering from a major complication (observed empyema rate was 1.4%) [18]. Similar positive results were reported by Harrison et al., who showed that the outpatient setting in 200 patients discharged with a chest tube between January 2017 and December 2019 is safe (complications rate 8%, readmission rate 6%) and cost-effective (annual total cost saving was US$149 032) [19].

Recently, there is a growing interest in performing an anatomical segmentectomy in patients with NSCLC <2 cm as suggested in several well-conducted studies [20–25]. Few of those reports showed a similar PAL rate after segmentectomy when compared to lobectomy, while some authors reported a higher prolonged air leak rate with segmentectomy [22–24].

Specifically, Saji and colleagues reported, in the JCOG 0802 trial, an increased rate of PAL in the segmentectomy group versus lobectomy, 6.5% and 3.4%, respectively (P = 0.04) [23].

Similarly, Suzuki et al. published a randomized controlled trial to confirm the non-inferiority of segmentectomy to lobectomy regarding the prognosis. A multivariate analysis showed, however, an increased air leak rate in the segmentectomy group when compared to the lobectomy one [25].

A possible explanation of the difference in PAL after segmentectomy when compared to lobectomy is the need of a more complex parenchymal dissection across multiple, less defined, planes.

Considering the increasing trend of sublobar anatomical resections and the earlier hospital discharges in the context of Early Recovery After Surgery protocols, the frequency of patients discharged home with a chest tube in situ may potentially become an increasing concern over time [26].

As showed above, currently there is no consensus whether discharging patients with chest tube after lung resection is safe. The heterogeneity of included patients and the variability of clinical practices represent a common limitation that does not allow to state firm conclusions (Table 1).

DISCHARGE AFTER CHEST DRAIN INSERTION DUE TO PNEUMOTHORAX

Primary Spontaneous Pneumothorax (PSP) is a relatively frequent disease that involves healthy young adults; concurrently, Secondary Spontaneous Pneumothorax (SSP) is related to an underlying pathology of the lung, such as emphysema or fibrosis [27]. Current guidelines suggest aspiration or chest drain insertion for 1st episodes [28, 29], which often require hospitalization for observation or until chest tube removal, hence leading to high costs for healthcare systems and often unnecessary distress for patients. In the last decades, several studies explored an ambulatory management of 1st episodes of spontaneous pneumothorax [30–35]. According to various study protocols or local best-practice practices, a small-bore (8–14 Fr) chest drain was to be connected to a one-way valve or, in some cases, portable devices such as Pleural Vent, thus allowing the patients to be sent home subsequently with reassessment every 24–48 h in an outpatient setting until chest tube removal when the lung has re-expanded and no air leak was detected. Otherwise, patients were to be hospitalized for further treatment or surgery in case of PAL or complications. In almost all studies, results showed that the outpatient management was safe and feasible. Success rates, evaluated as resolution of pneumothorax without early recurrence ranged between 65% and 84.5% in several retrospective studies [30, 31]. SSP showed lower success rate compared to PSP even though these results were not significant, and some authors advocated for the safety and feasibility of ambulatory management for SSP as well [32, 35]. In a large British prospective randomized controlled trial, the RAMPP trial, Hallifax and colleagues compared outcomes of patients with PSP randomized into standard guidelines group (aspiration and/or chest drain insertion) or ambulatory management group (treated with insertion of an ambulatory device, namely Rocket pleural vent). The trial enrolled 236 patients, equally divided between the 2 treatment groups, and primary end-point was duration of in-hospital stay in the 1st 30 days since randomization, which was significantly lower in patients in the ambulatory management with a median difference of 2 days [median stay 0 days (interquartile range; IQR 0–3) versus 4 days (IQR 0–8), P < 0.0001]. However, the authors reported a significantly longer time to successful completion in the outpatients’ group [median time to successful completion of treatment 3 days (IQR 1–6) versus 2 days (IQR 0–6), P = 0.0040]; they attributed it to the complexity and disadvantages of the outpatient treatment itself that does not allow for a daily re-valuation of the clinical situation [36]. Another randomized trial focused on the ambulatory management of SSP; the trial failed to achieve the intended recruitment target, and only 41 patients were eventually randomized. In this study, there was no significant difference in the in-hospital LOS in the first 30 days after randomization [6 days (IQR 1.00–15.50) for the ambulatory arm and 6 days (IQR 2.25–15.50) in the standard care group, P = 0.77]. At 12-month follow-up, recurrence rates of 24% and 28% were reported in the ambulatory arm and controlled group, with no significant difference [37].

In 2013, Choi et al. retrospectively compared outcome of patients with a PSP treated with either small bore catheter connected to a Heimlich valve and managed ambulatory or with a closed thoracostomy and hospitalized; at a 6-month follow-up, authors reported an 8% and 15% recurrence rate in the ambulatory and standard group, respectively, but this difference was not significant (P > 0.05) [33].

In the RAMPP trial, authors acknowledge a significant higher proportion of serious adverse events in the outpatients group compared to the control group [14 events (12%) versus 0 events (0%), P < 0.0001]. In fact, these were mainly complications that required hospitalization and insertion of a larger chest tube, such as enlarging pneumothorax, kinked or blocked device or its dislodgement [36]. Similar complications were reported in other experiences, while others reported a significant higher complication rate in the control group with no complications in the ambulatory group [31–33]. Walker observed a different rate of complication according to the device that was used in the ambulatory setting: pleural vent was related to a 46% of treatment failure, while no failures were reported in those treated with chest drain connect to the atrium pneumostat device [37]. Nevertheless, no cases of death were reported in the literature for patients treated with an ambulatory management of pneumothorax.

Beyond clinical benefits and patients’ satisfaction, the usage of an outpatient setting for the management of PSP and SSP can potentially lead to positive cost-effectiveness balance. Based on the data of the RAMPP trial, Luengo-Fernandez analysed the cost-effectiveness of the ambulatory management of PSP; the authors reported a significant cost saving per patient in this setting (–788 £) [38]. Similarly, Khan et al. demonstrated a 1118 £ saving per patient also considering SSP [28]. Finally, Choi et al. calculated an approximative 1000 € saving for ambulatory patients, but in case of outpatients treatment failure, there was roughly 200 € additional costs compared to standard treatment [33]. Moreover, the standardization of patients’ management in an ambulatory setting could potentially allow to entrust the outpatient management to a dedicated nurse practitioner that could lead to further cost saving [19].

Ambulatory management of PSP and SSP is a valuable option, which seem to be safe and at least equally effective when compared to standard in-hospital treatment. Moreover, outpatient management could lead to an effective cost saving. Nevertheless, the end-points of different studies are so far very heterogeneous and therefore it is currently difficult to draw definitive conclusions (Table 2).

POST-DISCHARGE MANAGEMENT

The high rates of re-admission and empyema reported in some studies might dictate, in our opinion, a proactive approach in the post-discharge period.

To offset the risk of empyema, some authors have been prescribing antibiotics on discharge although there are no data from randomized trials to support this practice [4, 9, 14].

As such, no consensus exists so far about the need of an antibiotic therapy for patients discharged with chest tube and therefore more high-quality data are needed.

However, many publications advocate for the need of a post-discharge monitoring programme with specialized nurses, which can be available for patients identifying in a timely manner possible complications [4, 18].

Ideally, an integrated programme with specialized nurse/s in thoracic surgery should be available when the outpatient setting of patients with PAL or excessive fluids drainage is required.

Prior to discharge, patients should receive all the information on the routine course of recovery and possible complications to watch for. After discharge, nurses’ home visits, educational phone calls along with a 24-h hotline may reduce readmissions or emergency room visits post-discharge [39, 40].

The addition of a mobile app, as previously reported by our group, even if in a different subgroup of patients, may also reduce the rate of readmission or unnecessary emergency department visits and hence might potentially be beneficial in this setup [41].

Limitations

While we tried with our review of the literature to provide a rigorous and wide overview on the topic, the narrative design of the manuscript and the heterogenicity of the publications on the subject would suggest that a certain level of subjectivity in the choice of studies included is likely. However, our aim was to highlight the pros and cons of discharging patients with chest tube in situ while trying to avoid a persuasive effect in the decision-making process [42].

CONCLUSION

Early discharge of patients with chest tube after lung surgery or an episode of pneumothorax may result in reduced LOS and hospital costs. However, it should be kept in mind that the outpatient setting might potentially increase the rate of some complications such as empyema. The heterogeneity of published data advocates the implementation of future studies, possibly with a prospective design, focusing on possible measures to increase the safety in this subgroup of patients (e.g. systematic use of antibiotic prophylaxis, telemonitoring, standard presence of a dedicated homecare team). Moreover, a cost analysis should be incorporated into the design of future trials in order to evaluate the financial impact of an outpatient setting. The literature strongly suggests that some model of post-discharge active follow-up setup should be in place before considering discharging patients home with a chest drain in place, combined with an ability for a timely assessment and, when needed, an intervention or admission for those patients who develop complications.

FUNDING

This paper was published as part of a supplement financially supported by Medela.

Conflict of interest: none declared.

DATA AVAILABILITY

All data are incorporated into the article and its online supplementary material.

Author contributions

Fabrizio Minervini: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Resources; Supervision; Writing—original draft; Writing—review and editing. Pietro Bertoglio: Data curation; Formal analysis; Resources; Writing—original draft; Writing—review and editing. Alessandro Brunelli: Supervision; Writing—review and editing. Yaron Shargall: Supervision; Writing—review and editing.

REFERENCES

ABBREVIATIONS

ABBREVIATIONS
 
• IQR

  Interquartile range

 
• LOS

  Length of stay

 
• LOWESS

  Locally weighted scatterplot smoothing

 
• PAL

  Persistent air leak

 
• PSP

  Primary Spontaneous Pneumothorax

 
• SSP

  Secondary Spontaneous Pneumothorax