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CHAPTER 57: Massive Hemoptysis 509

and enters the second chamber, often called the water seal chamber, • Davies HE, Davies R, Davies C, et al. Management of pleural infec-
below the water level and bubbles through the water seal preventing tion in adults: British Thoracic Society Pleural Disease Guideline
return of air to the patient’s thoracic cavity. The air enters the third 2010. Thorax. 2010;65(suppl 2):ii41-ii53.
chamber which is connected to wall suction. The height of water in the
suction chamber indicates the amount of suction applied and is typically • Davies HE, Mishra EK, Kahan BC, et al. Effect of an indwelling
between −10 and −30 mm Hg, but often varies based on the indication pleural catheter vs chest tube and talc pleurodesis for relieving
for chest tube insertion. An atmospheric vent prevents the application of dyspnea in patients with malignant pleural effusion: the TIME2 ran-
excessive suction. While different collection systems may vary, this basic domized controlled trial. JAMA. June 13, 2012;307(22):2383-2389.
design is common to most available models. There is some evidence to • Koenig SJ, Narasimhan M, Mayo PH. Thoracic ultrasonography for
guide the level of suction that should be used. For postoperative and the pulmonary specialist. Chest. November 2011;140(5):1332-1341.
trauma patients there is evidence that suction at −20 mm Hg is not supe- • MacDuff A, Arnold A, Harvey J. Management of spontaneous
rior to water seal at resolving pneumothorax or shortening chest tube pneumothorax: British Thoracic Society Pleural Disease Guideline
duration. 48,49 There is less evidence to guide the application of suction 2010. Thorax. August 2010;65(suppl 2):ii18-ii31.
in medical patients. In general, the lowest level of suction, including no • Marshall MB, Deeb ME, Bleier JI, et al. Suction vs water seal after
suction, should be used to fully expand the lung and resolve a pneumo- pulmonary resection: a randomized prospective study. Chest.
thorax. Chest imaging, typically CXR or ultrasound, should be used to 2002;121:831-835.
determine the efficacy of lung expansion at a particular suction level. If • Oxman DA, Issa NC, Marty FM, et al. Postoperative antibacte-
suction is applied to assist with pleural fluid drainage, then −20 mm Hg rial prophylaxis for the prevention of infectious complications
is often applied initially with use of chest imaging studies to determine associated with tube thoracostomy in patients undergoing elective
the adequacy of pleural fluid drainage. general thoracic surgery: a double-blind, placebo-controlled, ran-
The amount of air or fluid being drained by a chest tube should be domized trial. JAMA Surg. May 2013;148(5):440-446.
assessed frequently in order to determine the earliest time it can be safely
removed. An air leak can be quantified by the number of columns that • Rahman NM, Maskell NA, West A, et al. Intrapleural use of tissue
air bubbles through the water seal chamber (typically there are 7 side- plasminogen activator and DNase in pleural infection. N Engl J
by-side columns). In addition, the physician should notice whether the Med. August 11, 2011;365(6):518-526.
air leak occurs during forced exhalation or normal exhalation, which • Roberts ME, Neville E, Berrisford RG, Antunes G, Ali NJ. Management
suggests a small alveolar-pleural fistula. Alternatively, an air leak that of a malignant pleural effusion: British Thoracic Society Pleural
occurs during inspiration or continuously suggests a larger defect in Disease Guideline 2010. Thorax. August 2010;65(suppl 2):ii32-ii40.
the pleura and may indicate that a bronchopleural fistula is present. In • Younes RN, Gross JL, Aguir S, et al. When to remove a chest tube?
general, chest tubes should not be removed or clamped if an air leak A randomized study with subsequent prospective consecutive
persists as this suggests that air may accumulate in the pleural space, validation. J Am Coll Surg. 2002;195:658-662.
potentially leading to tension physiology and cardiac compromise
(ie, reduced venous return and cardiac output).
When placed for pneumothorax, chest tubes should be removed when
the lung is fully expanded and there is no evidence of continued air REFERENCES
leak. Some physicians advocate a trial of chest tube clamping for several
hours followed by a repeat chest imaging study. Reaccumulation of the Complete references available online at www.mhprofessional.com/hall
50
pneumothorax during the clamping trial suggests a small air leak is still
present. However, there are limited data to guide the use of clamping in
medical patients and the surgical literature is conflicting. 29,51,52 Similarly
there is some controversy as to whether a patient should be liberated CHAPTER Massive Hemoptysis
from mechanical ventilation before a chest tube, initially placed for
should drain less than 100 to 300 mL/d before chest tube removal is 57 Alexander Benson
pneumothorax, is removed. Chest tubes placed for pleural effusion
Richard K. Albert
contemplated. There is some evidence that a threshold of <200 mL/d
in the postoperative setting is similar to lower threshold volumes with
respect to hospitalization time or incidence of significant pleural fluid
reaccumulation. 53 KEY POINTS
Petroleum gauze dressing, scissors, and several 4-by-4 in bandages
should be assembled when a chest tube is ready to be removed. The • Ensure proper oxygenation and secure the patient’s airway if necessary.
sutures wrapped around the chest tube should be cut and the patient • Correct coagulation abnormalities.
should breath-hold during chest tube removal. The clinician removing • Localize bleeding with bronchoscopy (unstable patient) or CT scan
the tube should pull the tube in one motion with immediate closure (stable patient) and position the bleeding site in a dependent position.
of the skin incision by tightening and then tying both ends of the • In unstable, hypoxemic patients consider urgent bronchoscopy for suc-
mattress suture. This motion should close the skin and prevent air entry
up the chest tube tract and into the pleural space. Finally, petroleum tioning, endobronchial hemostatic therapy and balloon tamponade.
gauze dressing should be placed over the sutures and covered with dry • Interventional radiology-guided bronchial artery embolization is
bandages. effective and should be performed after initial stabilization.
• Surgery is required in rare circumstances.
KEY REFERENCES
• Alphonso N, Tan C, Utley M, et al. A prospective randomized INTRODUCTION
controlled trial of suction versus non-suction to the under-water
seal drains following lung resection. Eur J Cardiothorac Surg. Hemoptysis, or the expectoration of blood, can result from a wide variety
2005;27:391-394. of illnesses (Table 57-1). The prevalence of these different etiologies
depends on the characteristics of the specific patient population studied.

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