Drainage of the pleural space has been practiced since the time of hippocrates and chest tubes have been routinely used to drain the pleural space particularly after lung surgery. However, despite being used for long time in thoracic surgeries, there is no definitive consensus over its management. Chest tube management has been determined primarily by the tradition and personal experience of the surgical team rather than a scientifically validated management protocol. There is wide variation in clinical practice regarding the size and number of chest tubes to be inserted, the timing of removal of chest tubes, and management of chest tube in presence of minimal air leaks and ongoing drainage of pleural fluid. Further there is no consensus on the volume of pleural fluid draining at which a chest tube can be removed safely. 

 Air leak is one of the most common complications after pulmonary resection. Conventional teaching favors chest tube to be retained till air leak stops completely and there is pleura to pleura apposition. However recent studies suggested that it may be possible to discharge a patient with minimum air leak and non expanding residual pneumothorax if patient is stable.   Recent work by cerfolio et al suggest early discharge of patients with air leak is possible with Heimlich valve.

 The other common cause for which chest tubes are retained for prolonged duration is persistent drainage of pleural fluid. This also has been shown to be the most common cause of delayed discharge from hospital. Though there is no standard definition of persistent chest drain output, a quantity below 100- 150 ml has long been arbitrarily used below which chest tube removal is considered safe. However many randomized trials advocate a higher drainage criteria ranging from 300ml to as high as 500ml per 24 hours.

 In a large retrospective cohort study by cerfolio et al in 2,077 patients ,no significant difference was found in complication and readmission rates when chest tubes were removed at a drainage of 450 ml as compared to their usual practice of 250 ml.

 Therefore it is evident that air leak and prolonged chest tube drainage are the 2 major reasons for delayed chest tube removal and prolonged postoperative stay. Studies in the recent years have been aiming at early removal of chest tube and shortening the post operative stay using validated protocol based management of chest tubes. These studies have shown that the chest tube removal time can be shortened from 4-5 days to 3 days  in most patients and post operative discharge can be hastened from 7-8 days  to 4-5  days  with protocol based management.  Further it has been shown in the west that patients with minimum air leak and residual stable pleural space can be safely discharged on Heimlich valve . All these studies are from developed nations where majority of pulmonary resections are done for malignancies and emphysematous condition, whereas as in our setup majority of thoracic surgeries are being performed for inflammatory lung diseases where pleural physiology is conceivably different and algorithm developed for non inflammatory conditions should not be indiscriminately applied to our patients.

 This study is being planned with the intent to develop a protocol based management of chest tubes, especially with regard to management of air leaks and chest tube drainage in Indian setting. The ultimate aim is to reduce patient morbidity by decreasing the duration of chest tube and postoperative hospital stay.

RESULTS

Out of 122 patients recruited in study, 53% patients underwent pulmonary resections, and 38% patient underwent surgery for mediastinal pathology. ICD protocol could be followed in 101 patients and 84 patients were discharged according to the protocol. Chest tube dwelling time and postoperative hospital stay was significantly less in patient in whom protocol was followed vis a vis those in whom it could not be followed. Reinsertions were significantly higher in patients in whom protocol could not be followed. No difference in readmissions and mortality was noted. Comparison with data before starting of the study, revealed an early ICD removal and discharge was possible in prospective patients