CORRESPONDENCE To THE EDITOR:
My colleagues and I are grateful to Dr. S. R. Powers, Jr., for his complimentary editorial in the April issue (Ann Thorac Surg 19:480, 1975) concerning our article entitled “Management of Flail Chest Without Mechanical Ventilation,’’which was published in the same issue. While we are in general agreement with his comments, I must disagree with the following statement: “In reviewing their data, it is apparent that the patients treated without mechanical ventilation were a highly selected group who did not appear to suffer from severe ventilatory insufficiency.” The most important point in our article is that severe respiratory insufficiency rarely occurs in flail chest if the underlying pulmonary contusion is treated aggressively by the techniques outlined. We think the so-called respiratory distress syndrome, which frequently occurs in patients with multiple injuries, is usually due to noncolloid fluid overload. These 10 consecutive unselected patients all met Lloyd’s criteria of moderate or severe chest injury. Thus, we attribute the absence of respiratory insufficiency to treatment, not to patient selection. Our clinical series currently consists of 28 consecutive unselected patients with flail chest. There has been 1 nonrespiratory death. Only 3 patients, 1 with antecedent obstructive airway disease and 2 with massive chest wall instability and multiple injuries, have required prolonged mechanical ventilation. In the remaining 25 patients mechanical ventilation was either avoided or used only briefly, usually following operations for associated injuries. The average duration of hospitalization has been reduced to less than 50% of that in a prior series of similar patients in the same institution treated with traditional tracheostomy and mechanical ventilation. Division of Cardiothoracic Surgery The University of Texas Health Science Center at Sun Antonio 7703 Floyd Curl Dr. Sun Antonio, Tex. 78284
To
THE
J. KENT TRINKLE, M.D.
EDITOR:
Just as “a camel is a horse designed by a committee,” so a chest drainage system to please all surgeons is unlikely to drain the chest. Using the logic popularized by Kinsey (if everyone is doing it, it can’t be sin), Munnell and Thomas [ 11 first survey common chest drainage habits, then discuss their own notions on right and wrong in chest drainage. Unfortunately, with the separate waterseal recommended by the authors (as in the Pleurevac, for example?) the intervening air space transmits chest tube respiratory pressure changes so poorly that external suction must be used to overcome “air lock.” Although ordinary waterseal is simple, safe, and generally sufficient without suction [2], Munnell and Thomas conclude that a separate waterseal plus suction will somehow simplify patient care and reduce costs. Until Board certification or Society membership guarantees infallibility, it would seem inappropriate to survey methods without reporting applications and results. We have all seen major errors in closed chest drainage (such as always clamping the tube for transportation), and we know there are excellent surgeons who will continue to do this despite obvious and known hazards 121, but that hardly justifies designing another system to help per-
VOL. 20, NO. 6, DECEMBER, 1975
72 1
Correspondence petuate this bad habit. Similarly, although a Penrose drain would undoubtedly provide adequate mediastinal drainage following simple sternotomy, only a well-handled, welldesigned pleural drainage system can prevent unnecessary morbidity and mortality with major air leak from lung. (Try to clamp that tube for transportation!) ARNDTVON HIPPEL,M.D. Suite 203 3300 Providence Ave. Anchoruge, Alaska 99504
References 1. Munnell, E. R., and Thomas, E. K. Current concepts in thoracic drainage systems. Ann Thorac Surg 19:261, 1975. 2. von Hippel, A. Chest Tubes and Chest Bottles. Springfield, Ill.: Thomas, 1970.
To THE EDITOR: Dr. von Hippel’s letter criticizing our recent paper on thoracic drainage systems (Ann Thoruc Surg 19:261, 1975) was read with great disappointment. A genuine, rather exhaustive effort was made to ascertain the needs of experienced thoracic surgeons, as they saw them, in managing chest drainage in their patients. If these surgeons do not know what is necessary to drain a chest, I doubt that it can be identified. Beginning with information from a questionnaire, statistics were developed that indicated by and large what is typical. Whether Dr. von Hippel likes it or not, many of his colleagues do clamp chest tubes at times. Von Hippel is an advocate of waterseal alone, as evidenced by his book and recent comments, but our work documents that a waterseal system is used by only 28% of thoracic surgeons; all others use some type of suction. Furthermore, waterseal by itself has serious limitations, as already identified by Batchelder, Enerson, Roe, and others (refs. 1 , 2 , 3 , 5 , and 6 of the article). In essence, like a “fluid-filled loop,” as liquids collect in a waterseal bottle the forces needed for drainage are increased, be it by the mechanics of respiration, gravity, or added suction. As of today, of the myriad drainage systems available, none meets the needs identified by our colleagues in response to the query. All have limitations, including waterseal alone. This single letter of dissent is far outweighed by the positive replies. T h e worthiness of the evaluation became more apparent as the project evolved. First, dozens of the respondents added footnotes on their questionnaires saying that this type of study was “long overdue,” “sorely needed,” and “would be a distinct contribution to thoracic surgery.” Furthermore, a 67% response to the questionnaire substantiates strong interest. It is true that one system may not work for all, but it is also true that the need for a system that is basically more satisfactory has been unquestionably emphasized by the evidence elicited in our article and in numerous personal communications. I f a drainage system should evolve as a result of the questionnaire, it seems likely that it could please many and bring about a drainage system more universally safe, effective, simple, and less costly.
EDWARD R. MUNNELL,M.D. Oklahoma City Clinic 301 Northwest Twelfth St. Oklahoma City, Okla. 73103
To THE EDITOR:
T h e surgical treatment for transposition of the great arteries (TGA) must now be considered to be midway between the palliative and curative end of the spectrum. T h e
722
THE ANNALS OF THORACIC SURGERY
My colleagues and I are grateful to Dr. S. R. Powers, Jr., for his complimentary editorial in the April issue (Ann Thorac Surg 19:480, 1975) concerning our article entitled “Management of Flail Chest Without Mechanical Ventilation,’’which was published in the same issue. While we are in general agreement with his comments, I must disagree with the following statement: “In reviewing their data, it is apparent that the patients treated without mechanical ventilation were a highly selected group who did not appear to suffer from severe ventilatory insufficiency.” The most important point in our article is that severe respiratory insufficiency rarely occurs in flail chest if the underlying pulmonary contusion is treated aggressively by the techniques outlined. We think the so-called respiratory distress syndrome, which frequently occurs in patients with multiple injuries, is usually due to noncolloid fluid overload. These 10 consecutive unselected patients all met Lloyd’s criteria of moderate or severe chest injury. Thus, we attribute the absence of respiratory insufficiency to treatment, not to patient selection. Our clinical series currently consists of 28 consecutive unselected patients with flail chest. There has been 1 nonrespiratory death. Only 3 patients, 1 with antecedent obstructive airway disease and 2 with massive chest wall instability and multiple injuries, have required prolonged mechanical ventilation. In the remaining 25 patients mechanical ventilation was either avoided or used only briefly, usually following operations for associated injuries. The average duration of hospitalization has been reduced to less than 50% of that in a prior series of similar patients in the same institution treated with traditional tracheostomy and mechanical ventilation. Division of Cardiothoracic Surgery The University of Texas Health Science Center at Sun Antonio 7703 Floyd Curl Dr. Sun Antonio, Tex. 78284
To
THE
J. KENT TRINKLE, M.D.
EDITOR:
Just as “a camel is a horse designed by a committee,” so a chest drainage system to please all surgeons is unlikely to drain the chest. Using the logic popularized by Kinsey (if everyone is doing it, it can’t be sin), Munnell and Thomas [ 11 first survey common chest drainage habits, then discuss their own notions on right and wrong in chest drainage. Unfortunately, with the separate waterseal recommended by the authors (as in the Pleurevac, for example?) the intervening air space transmits chest tube respiratory pressure changes so poorly that external suction must be used to overcome “air lock.” Although ordinary waterseal is simple, safe, and generally sufficient without suction [2], Munnell and Thomas conclude that a separate waterseal plus suction will somehow simplify patient care and reduce costs. Until Board certification or Society membership guarantees infallibility, it would seem inappropriate to survey methods without reporting applications and results. We have all seen major errors in closed chest drainage (such as always clamping the tube for transportation), and we know there are excellent surgeons who will continue to do this despite obvious and known hazards 121, but that hardly justifies designing another system to help per-
VOL. 20, NO. 6, DECEMBER, 1975
72 1
Correspondence petuate this bad habit. Similarly, although a Penrose drain would undoubtedly provide adequate mediastinal drainage following simple sternotomy, only a well-handled, welldesigned pleural drainage system can prevent unnecessary morbidity and mortality with major air leak from lung. (Try to clamp that tube for transportation!) ARNDTVON HIPPEL,M.D. Suite 203 3300 Providence Ave. Anchoruge, Alaska 99504
References 1. Munnell, E. R., and Thomas, E. K. Current concepts in thoracic drainage systems. Ann Thorac Surg 19:261, 1975. 2. von Hippel, A. Chest Tubes and Chest Bottles. Springfield, Ill.: Thomas, 1970.
To THE EDITOR: Dr. von Hippel’s letter criticizing our recent paper on thoracic drainage systems (Ann Thoruc Surg 19:261, 1975) was read with great disappointment. A genuine, rather exhaustive effort was made to ascertain the needs of experienced thoracic surgeons, as they saw them, in managing chest drainage in their patients. If these surgeons do not know what is necessary to drain a chest, I doubt that it can be identified. Beginning with information from a questionnaire, statistics were developed that indicated by and large what is typical. Whether Dr. von Hippel likes it or not, many of his colleagues do clamp chest tubes at times. Von Hippel is an advocate of waterseal alone, as evidenced by his book and recent comments, but our work documents that a waterseal system is used by only 28% of thoracic surgeons; all others use some type of suction. Furthermore, waterseal by itself has serious limitations, as already identified by Batchelder, Enerson, Roe, and others (refs. 1 , 2 , 3 , 5 , and 6 of the article). In essence, like a “fluid-filled loop,” as liquids collect in a waterseal bottle the forces needed for drainage are increased, be it by the mechanics of respiration, gravity, or added suction. As of today, of the myriad drainage systems available, none meets the needs identified by our colleagues in response to the query. All have limitations, including waterseal alone. This single letter of dissent is far outweighed by the positive replies. T h e worthiness of the evaluation became more apparent as the project evolved. First, dozens of the respondents added footnotes on their questionnaires saying that this type of study was “long overdue,” “sorely needed,” and “would be a distinct contribution to thoracic surgery.” Furthermore, a 67% response to the questionnaire substantiates strong interest. It is true that one system may not work for all, but it is also true that the need for a system that is basically more satisfactory has been unquestionably emphasized by the evidence elicited in our article and in numerous personal communications. I f a drainage system should evolve as a result of the questionnaire, it seems likely that it could please many and bring about a drainage system more universally safe, effective, simple, and less costly.
EDWARD R. MUNNELL,M.D. Oklahoma City Clinic 301 Northwest Twelfth St. Oklahoma City, Okla. 73103
To THE EDITOR:
T h e surgical treatment for transposition of the great arteries (TGA) must now be considered to be midway between the palliative and curative end of the spectrum. T h e
722
THE ANNALS OF THORACIC SURGERY
