title: Optimal technique for the removal of chest tubes after pulmonary resection.
abstract: OBJECTIVE
  The objective is to determine the optimal manner to remove a chest tube after pulmonary resection.
  
  
  METHODS
  This was a prospective, randomized single-institution study. Patients who underwent elective thoracotomy for pulmonary resection by 1 or 2 general thoracic surgeons were randomized to have their chest tube removed on either full inspiration or full expiration. Both patient groups performed a Valsalva maneuver during tube removal. Outcomes included the incidence of clinically nonsignificant pneumothorax (defined as a new or increased pneumothorax on the post-chest tube removal chest roentgenogram in asymptomatic patients), symptoms, delayed discharge, and the need for a new chest tube.
  
  
  RESULTS
  Between November 2008 and June 2011, 1189 patients underwent pulmonary resection, and of these 342 met the criteria for the study. Of the 179 patients randomized to have their chest tube removed on full inspiration, 58 (32%) had a larger or new pneumothorax after chest tube removal and 5 (3%) required intervention or delayed discharge. Of the 163 patients randomized to have their chest tube removed on full expiration, 32 (19%; P = .007) had a larger or new pneumothorax after chest tube removal, and only 2 (1%) required intervention or delayed discharge (P = .78).
  
  
  CONCLUSIONS
  Removal of chest tubes at the end of expiration leads to a lower incidence of non-clinically significant pneumothorax than at the end of inspiration. Because of these findings, this study was closed early and was thus underpowered for finding a statistically significant difference in the rare (1%-3%) clinically significant pneumothoraces.
authors.affiliation: Section of Thoracic Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Ala 35294, USA.
authors.forename: Robert James
authors.initials: RJ
authors.lastname: Cerfolio
authors.forename: Ayesha S
authors.initials: AS
authors.lastname: Bryant
authors.forename: Loki
authors.initials: L
authors.lastname: Skylizard
authors.forename: Douglas J
authors.initials: DJ
authors.lastname: Minnich
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015505:Chest Tubes; D016009:Chi-Square Distribution; D020878:Device Removal; D005260:Female; D006801:Humans; D008171:Lung Diseases / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011030:Pneumothorax / Q000209:etiology*; D011446:Prospective Studies; D012044:Regression Analysis; D013908:Thoracotomy; D016896:Treatment Outcome; D014636:Valsalva Maneuver