Wang et al.

Journal of Cardiothoracic Surgery (2019) 14:13

https://doi.org/10.1186/s13019-019-0842-x

RESEARCH ARTICLE Open Access

Digital chest drainage system versus

traditional chest drainage system after
pulmonary resection: a systematic review
and meta-analysis
Hong Wang1†, Wenbin Hu2†, Liang Ma2 and Yiran Zhang2*

Abstract
Background: Several randomized controlled trials (RCTs) and observational studies have compared the efficacy of
digital chest drainage system versus traditional chest drainage system. However, the results were inconsistent.
Methods: We searched the Web of Science and Pubmed for observational studies and RCTs that compared the
effect of digital chest drainage system with traditional chest drainage system after pulmonary resection. Eight
studies (5 randomized control trails and 3 observational studies) comprising 1487 patients met the eligibility criteria.
Results: Compared with the traditional chest drainage system, digital chest drainage system reduced the
risk of prolonged air leak (PAL) (RR = 0.54, 95%CI 0.40–0.73, p < 0.0001), and shortened the duration of
chest drainage (SMD = − 0.35, 95%CI -0.60 - -0.09, p = 0.008) and length of hospital stay (SMD = − 0.35,
95%CI -0.61 - -0.09, p = 0.007) in patients after pulmonary resection.
Conclusions: Digital chest drainage system is expected to benefit patients to attain faster recovery and
higher life quality as well as to reduce the risk of postoperative complications. Further RCTs with larger
sample size are still needed to more clearly elucidate the advantages of digital chest drainage system.
Keywords: Digital chest drainage system, Pulmonary resection, Postoperative care

Introduction needed to optimize the recovery of patients after pul-

Alveolar air leak is one of the most frequent compli- monary resection.
cations after pulmonary resection, which happened in Traditionally, an analog chest drainage system was
up to 50% patients [1]. Prolonged air leak (PAL), de- used for assessment of the postoperative air leak. How-
fined as an air leak persisting more than 5 days by ever, the traditional chest drainage system has several
the Society of Thoracic Surgeons Database, occurred limitations. On the one hand, it measures air leak in a
in approximately 8–15% patients after pulmonary re- subjective manner by observing bubbling in the water
section [2]. It had been shown that PAL was associ- chamber, thus interobserver disagreement is frequent,
ated with longer length of hospital stay, increased and small air leaks are difficult to determine. On the
hospitalization costs, increased risk of empyema, and other hand, the suction pressure of the traditional chest
other possible cardiopulmonary complications [3, 4]. drainage system may deviate from the set level due to
Thus, better approaches for postoperative care are the position of the water chamber. Recently, a digital
chest drainage system has been developed to solve these
problems, which uses digital sensors to monitor air flow
and pleural pressure continuously [5]. With the digital
* Correspondence: [email protected]
†
Hong Wang and Wenbin Hu contributed equally to this work.
chest drainage system, the pleural pressure can be con-
2
Department of Cardiothoracic Surgery, First Affiliated Hospital, Zhejiang stantly maintained by physicians independent of the de-
University School of Medicine, Hangzhou 310003, China vice position, and postoperative air leak can be evaluated
Full list of author information is available at the end of the article

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
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Wang et al. Journal of Cardiothoracic Surgery (2019) 14:13 Page 2 of 6

objectively. Several randomized controlled trials (RCTs) two authors (H Wang, W Hu) independently extracted
and observational studies have compared the efficacy of the data and evaluated the quality of the included
digital chest drainage system versus traditional chest studies. Any divergence was resolved by a third re-
drainage system. However, no meta-analysis has been viewer (Y Zhang). The following data was obtained
conducted to pool the results of these clinical trials so from each study: author, nationality, publication time,
far. number of patients in each study group, study design,
A meta-analysis and systematic review was performed baseline characteristics and clinical end points. Two
to compare the efficacy of digital chest drainage system authors evaluated the quality of the included litera-
with traditional chest drainage system. tures independently. The Newcastle-Ottawa scale was
applied to assess the quality of observational studies
Materials and methods (http://www.ohri.ca/programs/clinical_epidemiology/
Eligibility criteria oxford.asp). The following 3 aspects of an observa-
The inclusion criteria of literatures in the present tional study were evaluated using Newcastle-Ottawa
meta-analysis were (i) observational studies or scale: (1) the selection of the study cohort (or cases/
randomized trials, (ii) adults (≥18 years) undergoing controls), (2) the comparability of the cohorts (or
pulmonary resection (including lobectomy, segmen- cases/controls) and (3) the outcome assessment for a
tectomy, and wedge resection), (iii) studies comparing cohort study, or the determination of the exposure for
digital chest drainage system with traditional chest a case-control study. The Jadad scale was used to as-
drainage system, (iv) end points included prolonged sess the quality of randomized trials [7]. The following
air leak (defined as air leak duration ≥5 days), duration aspects of a randomized study were evaluated by the
of chest drainage and length of hospital stay. The ex- Jadad scale: randomization, double blinding, with-
clusion criteria were: (i) case reports or review articles, drawals and dropouts. A study was considered as
(ii) articles written in non-English language. high-quality if its score ≥ 3. The present meta-analysis
and systematic review was conducted following the
Search strategy PRISMA guidelines [8].
A literature search was conducted using the Web of Sci-
ence and Pubmed to identify relevant literatures pub- Statistical analysis
lished through January 2018. The search term used was The statistical analysis was performed according to
“digital thoracic drainage”. Two authors (H Wang, W previously described methods [6]. Briefly, we use Re-
Hu) independently applied the eligibility criteria to view Manager 5.2 (RevMan 5.2®, Nordic Cochrane
screen the literature search results, and the reference Center and Copenhagen, Denmark) to conduct the
lists of the included literatures were screened again for meta-analysis. We calculated Risk ratios (RRs) with a
more potential studies. Any divergence was resolved by 95% confidence interval (CI) using the Mantel–
a third reviewer (Y Zhang). Haenszel method in order to compare the risk of
prolonged air leak between digital chest drainage
Data abstraction and quality assessment system and traditional chest drainage system. To in-
Data abstraction and quality assessment were con- vestigate continuous measures (duration of chest
ducted using methods described previously [6]. Briefly, drainage and length of hospital stay), we calculated

Fig. 1 Flow diagram of the article selection process in this meta-analysis

Wang et al. Journal of Cardiothoracic Surgery (2019) 14:13 Page 3 of 6

Table 1 Characteristics of Included Studies drainage systems were used in 767 patients. The char-
Studies Year Country Number of Study Study acteristics of the studies included are shown in Table 1.
patients design quality The baseline characteristics of the patients are shown
Digital Traditional in Table 2.
Takamochi 2017 Japan 135 164 RCT High (5)
Waele 2017 Canada 53 50 RCT High (5) Prolonged air leak
Miller 2016 USA 20 40 POS S3; C1; O3 Five studies evaluated the incidence of prolonged air
Shoji 2016 Japan 112 121 ROS S3; C1; O3 leak [11, 12, 14, 16, 17]. Digital chest drainage sys-
Filosso 2015 Italy 40 40 POS S3; C1; O3
tem significantly reduced the risk of prolonged air
leak compared with traditional chest drainage system
Gilbert 2015 Canada 87 85 RCT High (5)
(RR = 0.54, 95%CI 0.40–0.73, p < 0.0001; Fig. 2). No
Pompili 2014 International 191 190 RCT High (5) significant heterogeneity was observed in the pooled
Brunelli 2009 Italy 82 77 RCT High (4) group of studies (I2 = 48%, Chi2 = 7.66, p = 0.10; Fig. 2).
RCT randomized control trial, ROS retrospective observational study, POS Among the five studies, four studies were randomized
prospective observational study
control trials [11, 12, 16, 17], in this subgroup, the
risk of prolonged air leak was still lower in digital
standardized mean difference (SMD) with a 95%CI group than in traditional group (RR = 0.59, 95%CI
using the Inverse Variance method. Forest graphs 0.43–0.82, p = 0.002). One study was observational
were applied to present the meta-analysis results. study [14], which the risk of prolonged air leak was
The statistical heterogeneity of included literatures also lower in digital group than in traditional group
was assessed by I2 statistic. I2 values ≤50%, 50–74 (RR = 0.33, 95%CI 0.15–0.75, p = 0.008).
and ≥ 75% indicate low, moderate and high hetero-
geneity [9]. A fixed-effects model was chosen to per-
form the meta-analysis when the I2 value was ≤50%. Duration of chest drainage
A random-effects model was chosen when the I2 Eight studies reported the duration of chest drainage
value was > 50%. P-value < 0.05 was considered as [10–17]. Among the 8 studies, two studies presented
statistically significant. the data in a mean ± standard deviation form [11, 14],
and meta-analysis of these two studies suggested that
Results digital chest drainage system significantly reduced the
Description of the included studies duration of chest drainage compared with traditional
There were 80 articles identified through the literature chest drainage system (SMD = − 0.35, 95%CI -0.60 - -0.09,
search process. Among the 80 articles, 60 articles were p = 0.008; Fig. 3). The mean or median duration of chest
excluded as not being relevant. The remaining 20 drainage in the 8 studies were summarized in Table 3.
studies were assessed for eligibility, and 8 studies (5
randomized control trails and 3 observational studies) Length of hospital stay
[10–17] comprising 1487 patients met our eligibility Seven studies reported the length of hospital stay [11–17].
criteria and were included in this meta-analysis (Fig. 1). Among the 7 studies, two studies presented the data
Among the 1487 patients, digital chest drainage sys- in a mean ± standard deviation form [11, 14], and
tems were used in 720 patients, and traditional chest meta-analysis of these two studies suggested that

Table 2 The baseline characteristics of the patients

Studies Male (%) Age (years) VATS (%) Lobectomy (%)
Digital Traditional Digital Traditional Digital Traditional Digital Traditional
Takamochi 2017 51.8 48.7 66.6 ± 12.6 67.9 ± 10.9 NA NA 77 81.1
Waele 2017 48.1 51.9 68.5 ± 10.3 64.8 ± 10.6 56.2 43.8 50.8 49.2
Miller 2016 55 60 63 (48–77) 63 (52–79) 100 100 85 85
Shoji 2016 69 86 67 (20–88) 65 (19–87) NA NA 66 62
Filosso 2015 60 60 69 ± 7.9 67 ± 8.3 NA NA 80 78
Gilbert 2015 36.5 36.8 68 (60–72) 68 (60–75) 73.6 70.6 70.1 83.5
Pompili 2014 49 55 66.5 ± 12.1 65.9 ± 10.2 82 80 83 88
Brunelli 2009 70 77 66.1 ± 12.8 67.3 ± 8.4 NA NA NA NA
VATS video-assisted thoracic surgery, NA not available
Wang et al. Journal of Cardiothoracic Surgery (2019) 14:13 Page 4 of 6

Fig. 2 Forest graph presenting prolonged air leak. 95%CI: 95% confidence interval

digital chest drainage system significantly reduced the resection. First of all, the digital system can regulate its
length of hospital stay compared with traditional chest suction pressure according to the condition in the
drainage system (SMD = − 0.35, 95%CI -0.61 - -0.09, pleural cavity, and the pleural pressure can be main-
p = 0.007; Fig. 4). The mean or median length of hospital tained at a preset level within 0.1 cmH2O. It had
stay in the 7 studies were summarized in Table 3. been shown that wide oscillation in early postopera-
tive pleural pressure was associated with a higher in-
Discussion cidence of PAL [21]. Thus, the digital chest drainage
In the present meta-analysis and systematic review, we system may promote the sealing of air leaks by stabil-
found that compared to traditional chest drainage sys- izing the pleural pressure with minimal oscillation.
tem, digital chest drainage system reduced the risk of in- Second, the digital system measures the extent of air
cidence of prolonged air leak, and shortened the leak objectively, and the historical data can be
duration of chest drainage and length of hospital stay in exported and reviewed. Thus, the digital chest drain-
patients after pulmonary resection. age system reduces the interobserver variability, and
PAL remains a common complication after pulmon- helps medical personnel decide when to remove the
ary resection. Several studies had shown that PAL was chest tube more accurately. It had been proved by
associated with longer hospital stay and more hospital several clinical trials that digital chest drainage system
costs [18, 19]. It was also suggested that PAL was asso- not only reduced interobserver variability between dif-
ciated with an increased rate of postoperative morbid- ferent groups of medical staffs (surgeons, residents
ity, such as empyema, fever and pneumonia [20]. The and nurses) [22], but also between surgeons with
risk of PAL can be predicted by several preoperative comparable experience [23]. The reduced interob-
and intraoperative factors such as a low predicted post- server variability leads to shorter duration of chest
operative forced expiratory volume in 1 s (ppoFEV1), drainage and length of hospital stay. Furthermore, the
pleural adhesions and upper lobectomy [20]. Besides, digital system facilitates an early patient mobilization
improvement in postoperative chest drainage system is and improves postoperative physiotherapy, which can
an important approach to reduce PAL rate and acceler- reduce the risk of secretion and pneumonia, and facil-
ate the recovery. itates pulmonary re-expansion [14]. Finally, the digital
There are several advantages of digital chest drainage device such as the Thopaz chest drain system (Medela
system in management of patients after pulmonary Switzerland) can serve as a portable suction unit, and

Fig. 3 Forest graph presenting duration of chest drainage. 95%CI: 95% confidence interval
Wang et al. Journal of Cardiothoracic Surgery (2019) 14:13 Page 5 of 6

Table 3 Duration of chest drainage and hospital stay

Studies Duration of chest drainage (days), digital vs traditional Length of hospital stay
(days), digital vs traditional
Takamochi 2017 b 2.0 vs 3.0, p = 0.149 6.0 vs 7.0, p = 0.548
Waele 2017 a
2.3 vs 2.5, p = 0.055 4.8 vs 4.9, p = 0.403
Miller 2016 b 3.7 vs 5.3, p = 0.01 4.1 vs 5.6, p = 0.05
Shoji 2016 a
2.7 vs 3.7, p = 0.004 NA
Filosso 2015 a 3 vs 4, p = 0.0009 7 vs 8, p = 0.0385
Gilbert 2015 b
4.9 vs 5.6, p = 0.11 6.0 vs 6.0, p = 0.36
Pompili 2014 a 3.7 vs 4.7, p = 0.001 4.6 vs 5.6, p < 0.0001
Brunelli 2009 a
4.0 vs 4.9, p = 0.0007 5.4 vs 6.3, p = 0.007
NA not available
a
mean
b
median

patients can be discharged earlier with this system suggested that patients in the digital group had a more
[24]. positive perception of the chest drainage, which was asso-
Since the traditional chest drainage system is subject- ciated the comfort, portability and convenience of the
ive and inaccurate in judging air leak, there is risk of re- digital system [12].
moving the chest tube prematurely. In that situation, Recently, a meta-analysis of randomized controlled tri-
chest tube reinsertion is needed. A clamping test had als conducted by Zhou et al. suggested that digital chest
traditionally been taken to prevent this error. It had been drainage following pulmonary surgery reduced the dur-
suggested by Takamochi et al. that over 50% patients ation of chest tube placement, length of hospital stay, air
underwent clamping test before removing the chest tube leak duration and postoperative cost [25]. Compared to
in the traditional group, while none clamping test was their study, the present systematic review focused on pa-
taken in the digital group [17]. It had also been shown tients after pulmonary resection, and obtained similar
by Gilbert et al. that chest tube reinsertions for worsen- results. Another recent study discussed the postoperative
ing pneumothorax or subcutaneous emphysema after air leak pattern in lung cancer patients after pulmonary
chest tube removal occurred only in the traditional resection with the help of digital chest drainage system,
group, none chest tube reinsertion happened in the which suggested that the detailed air leak pattern can be
digital group [13]. used to predict the duration of air leakage and chest
Some clinicians hypothesized that the intermittent tube drainage [26].
suction pressure provided by the digital system may re-
duce the pressure gradient for fluid filtration across the
pleural membrane and lighten the inflammatory re- Conclusion
sponse. However, the study conducted by Waele et al. The present systematic review shows that digital chest
did not find such effect [16]. drainage system is expected to benefit patients to at-
Apart from objective outcomes, subjective outcome tain faster recovery and higher life quality as well as
(such as patient satisfaction) is also important in evaluat- to reduce the risk of postoperative complications.
ing chest drainage system. The multicenter study Further RCTs with larger sample size are still needed
conducted by Pompili et al. evaluated the patient satisfac- to more clearly elucidate the advantages of digital
tion with digital chest drainage system, and the result chest drainage system.

Fig. 4 Forest graph presenting length of hospital stay. 95%CI: 95% confidence interval
Wang et al. Journal of Cardiothoracic Surgery (2019) 14:13 Page 6 of 6

Abbreviations 11. Brunelli A, Salati M, Refai M, Di Nunzio L, Xiumé F, Sabbatini A. Evaluation of

CI: Confidence interval; PAL: Prolonged air leak; ppoFEV1: Predicted a new chest tube removal protocol using digital air leak monitoring after
postoperative forced expiratory volume; RCT: Randomized controlled trial; lobectomy: a prospective randomised trial. Eur J Cardiothorac Surg. 2010;
RR: Risk ratio; SMD: Standardized mean difference 37(1):56–60.
12. Pompili C, Detterbeck F, Papagiannopoulos K, Sihoe A, Vachlas K, Maxfield
Acknowledgements MW, et al. Multicenter international randomized comparison of objective
Not applicable. and subjective outcomes between electronic and traditional chest drainage
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This work was supported by the National Natural Science Foundation of Randomized trial of digital versus analog pleural drainage in patients with
China (Grant No. 81670350). or without a pulmonary air leak after lung resection. J Thorac Cardiovasc
Surg. 2015;150(5):1243–9.
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Authors’ contributions
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(I) Conception and design: YZ; (II) Administrative support: LM, YZ; (III)
hospitalization after video-assisted thoracoscopic surgery lung resection.
Provision of study materials or patients: HW, WH; (IV) Collection and
Ann Thorac Surg. 2016;102(3):955–61.
assembly of data: HW, WH; (V) Data analysis and interpretation: All authors;
16. De Waele M, Agzarian J, Hanna WC, Schieman C, Finley CJ, Macri J, et al.
(VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All
Does the usage of digital chest drainage systems reduce pleural
authors.
inflammation and volume of pleural effusion following oncologic
pulmonary resection?-a prospective randomized trial. J Thorac Dis. 2017;9(6):
Ethics approval and consent to participate
1598–606.
Not applicable.
17. Takamochi K, Nojiri S, Oh S, Matsunaga T, Imashimizu K, Fukui M, et al.
Comparison of digital and traditional thoracic drainage systems for
Consent for publication postoperative chest tube management after pulmonary resection: A
Not applicable. prospective randomized trial. J Thorac Cardiovasc Surg. 2017.
18. Abolhoda A, Liu D, Brooks A, Burt M. Prolonged air leak following radical
Competing interests upper lobectomy: an analysis of incidence and possible risk factors. Chest.
The authors declare that they have no competing interests. 1998;113(6):1507–10.
19. Melendez JA, Barrera R. Predictive respiratory complication quotient predicts
pulmonary complications in thoracic surgical patients. Ann Thorac Surg.
Publisher’s Note 1998;66(1):220–4.
Springer Nature remains neutral with regard to jurisdictional claims in
20. Brunelli A, Monteverde M, Borri A, Salati M, Marasco RD, Fianchini A.
published maps and institutional affiliations.
Predictors of prolonged air leak after pulmonary lobectomy. Ann Thorac
Surg. 2004;77(4):1205–10 discussion 1210.
Author details
1 21. Brunelli A, Cassivi SD, Salati M, Fibla J, Pompili C, Halgren LA, et al. Digital
Department of Surgery, Zhejiang University Hospital, Zhejiang University,
measurements of air leak flow and intrapleural pressures in the immediate
Hangzhou, China. 2Department of Cardiothoracic Surgery, First Affiliated
postoperative period predict risk of prolonged air leak after pulmonary
Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China.
lobectomy. Eur J Cardiothorac Surg. 2011;39(4):584–8.
22. McGuire AL, Petrcich W, Maziak DE, Shamji FM, Sundaresan SR, Seely AJ,
Received: 19 July 2018 Accepted: 14 January 2019
et al. Digital versus analogue pleural drainage phase 1: prospective
evaluation of interobserver reliability in the assessment of pulmonary air
leaks. Interact Cardiovasc Thorac Surg. 2015;21(4):403–7.
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