General Thoracic and Cardiovascular Surgery (2023) 71:1–11

https://doi.org/10.1007/s11748-022-01875-7

REVIEW ARTICLE

Advantages of applying digital chest drainage system

for postoperative management of patients following pulmonary
resection: a systematic review and meta‑analysis of 12 randomized
controlled trials
Liying Zhou1,2,3 · Kangle Guo1,2,3 · Xue Shang1,2,3 · Fenfen E1,2,3 · Meng Xu1,2,3 · Yanan Wu1,2,3 · Kehu Yang1,2,3 ·
Xiuxia Li1,2,3

Received: 19 July 2022 / Accepted: 20 September 2022 / Published online: 29 September 2022
© The Author(s), under exclusive licence to The Japanese Association for Thoracic Surgery 2022

Abstract
Objectives This meta-analysis aimed to evaluate the value of the chest digital drainage system for the postoperative manage-
ment of patients who have undergone pulmonary resection.
Methods We searched the PubMed, EMBASE, the Cochrane Library, and Web of Science databases for included randomized
controlled trials (RCTs) on the application of digital drainage systems versus the analog drainage system for patients with
lung disease after pulmonary resection. Dichotomous variables were evaluated using risk ratios (RRs) and 95% confidence
intervals (CIs), and mean and standardized mean differences (MDs and SMDs, respectively) with 95% CIs were used to
calculate continuous variables. Statistical analyses were performed using Stata and RevMan software.
Results In total, 12 RCTs involving 2000 patients were analyzed. Significant differences in duration of chest tube place-
ment (SMD =  −0.49; 95% CI =  −0.78 to −0.20), length of hospital stay (MD =−0.79 days; 95% CI = −1.24 to −0.34), and
number of chest tube clamping tests (RR = 0.74; 95% CI = 0.36–1.49) were observed between the two groups, which did not
significant differ in the occurrence of prolonged air leak or cardiopulmonary complication rate.
Conclusions The digital chest drainage system is mainly advantageous in the duration of chest tube placement, length of
hospital stay, and number of chest tube clamping tests. Future research should evaluate the requirements and economic impact
of using digital system in routine clinical practice.

Keywords Digital chest drainage system · Pulmonary resection · Lung disease · Meta-analysis

Introduction

Liying Zhou and Kangle Guo are co-first authors.

Patients undergoing pulmonary resection (such as wedge
resection, segmentectomy, lobectomy, and bilobectomy)
* Kehu Yang through open surgery (thoracotomy), video-assisted surgery,
yangkh-ebm@lzu.edu.cn or robotic-assisted surgery are thought to be at high risk
* Xiuxia Li for the development of an air leak during the postoperative
lixiuxia@lzu.edu.cn period [1]. Air leakage, which is defined as the escape of
1 air from the lung parenchyma into the pleural space after
Health Technology Assessment Center/Evidence‑Based
Social Science Research Center, School of Public chest surgery, remains a common and troubling complication
Health, Lanzhou University, 199 Donggang West Road, after lung resection and occurs in up to 50% of patients [2].
Lanzhou 730000, China It predicts a poor outcome with a prolonged hospital stay
2
Evidence Based Medicine Center, School of Basic Medical and complicated postoperative procedures [3, 4]. Moreo-
Sciences, Lanzhou University, 199 Donggang West Road, ver, according to the Thoracic and Cardiovascular Surgery
Lanzhou 730000, China
departments of The Cleveland Clinic Foundation, even the
3
Key Laboratory of Evidence Based Medicine and Knowledge slightest air leak can be problematic [5]. In addition, an air
Translation of Gansu Province, Lanzhou 730000, China

13
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2 General Thoracic and Cardiovascular Surgery (2023) 71:1–11
leak persisting for > 5 d (the current average hospital stay
following pulmonary lobectomy), which occurs in up to
18% of cases, has been defined as prolonged air leak (PAL),
which adopted by both the databases of the Society of Tho-
racic Surgeons and European Society of Thoracic Surgeons
[6]. It has been reported that PAL is the most common cause
of increased hospital stay, hospitalization cost, and risks of
empyema and other possible cardiopulmonary complica-
tions (such as thromboembolism, atelectasis, and pneumo-
nia) [3, 5, 7–9]. Furthermore, PAL can prolong the pain
and decrease the mobility of the patient due to prolonged
chest tube drainage placement [10]. Thus, optimization of
the postoperative patient management after lung resection
is important for optimal patient recovery.
Chest drainage via a traditional analog system or a digital
monitoring system is the standard management following
lung resection and requires monitoring of the evacuation
of air and fluids from the chest cavity [11–14]. Success-
ful chest tube management and removal depend on accu-
rate evaluation of air leakage [15]. Thus, the choice of the
chest drainage system plays a pivotal role in postoperative
success [16]. In the past, the traditional chest drainage sys-
tems were most commonly used. They rely on monitoring
the bubbling in the highest one of a sequentially numbered
series of columns in the water seal to provide a qualitative
assessment at a specific time point [17]. However, due to this
subjective assessment, the inter-observer discrepancies are
frequent, and small air leaks are hard to measure and figure
out. Particularly, the suction pressure of the traditional chest
drainage system may deviate from the set level because of
the position of the water chamber [18]. Since the develop-
ment of the first digital drainage system in 2007, the use
of this new chest tube removal protocol has been routinely
used in clinical practice [15, 19, 20]. Unlike the traditional
drainage system, it can quantify and graphically present the
degree of air leak over time. With the digital drainage sys-
tem, the pleural pressure preset by hospital staff can also be
constantly maintained independently of the tube and device
positions. As a consequence, according to data and not on
snapshot observations only as with traditional systems, it
may be effective in improving the scientific standard of chest
tube management through markedly reducing inter-observer
discrepancy in air leak assessment.
Is it better to use a digital or traditional drainage system
to reduce the incidence of air leaks? Two systematic reviews
with meta-analysis on this domain have been performed [18,
21]. One of them has determined the strength of evidence for
or against the digital and traditional chest drainage systems
following pulmonary surgery, whereas the other one only
included five randomized controlled trials (RCTs) and three
observational studies. Thus, a meta-analysis of RCTs that
directly compares the digital and traditional chest drainage
systems following pulmonary resection to establish whether
13
digital systems are superior to traditional analog systems in
terms of managing postoperative air leaks is very essential.
This systematic review and meta-analysis aimed to com-
pare the efficacy of the digital chest drainage system with
the traditional chest drainage system in patients following
pulmonary resection.
Methods
Search strategy
The PubMed, Web of Science, EMBASE, and the Cochrane
Central Register of Controlled Trials (CENTRAL) databases
were searched for RCTs published by 11 January 2022. In
addition, the WHO International Clinical Trials Registry
Platform (ICTRP) Search Portal, ClinicalTrials.gov, gray
publications, the references list (backward and forward) of
the included publications, and conference materials were
manually searched to identify additional articles published
by 12 January 2021. Keywords were used in combination
with the Medical Subject Heading (MeSH) terms includ-
ing “pulmonary surgery”, “chest drain”, “thorax drainage”,
“video-assisted thoracic surgery”, “lobectomy”, and “sub-
lobectomy”, adapting the search according to the database.
Inclusion and exclusion criteria
Studies published in English were included if they met all
the following PICOs eligibility criteria:
1. Par ticipants: all the studies involved adults
aged ≥ 18 years with lung disease who have undergone
pulmonary resection. All subgroups of pulmonary resec-
tion (including lobectomy, segmentectomy, and wedge
resection) and participants with any lung disease were
included.
2. Interventions: the patients in the intervention arm had
chest tubes connected to a digital chest drainage system
of any type (including Thopaz, Digivent, Drentech, and
ATMOS) after pulmonary resection.
3. Comparator: the patients in the control arm had chest
tubes connected to a traditional chest drainage system of
any type (including water-sealed, Express, and Atrium
Oasis) after pulmonary resection.
4. Outcomes: outcomes included the duration of chest tube
placement, length of hospital stay, number of chest tube
clamping tests, the occurrence of prolonged air leak, and
cardiopulmonary complication rate.
5. Study design: only RCTs were included. Reviews, expert
opinions, meta-analyses, duplicate or animal studies,
and studies that lacked original data or a control group
were excluded.
General Thoracic and Cardiovascular Surgery (2023) 71:1–11
Study selection and data extraction
Two independent reviewers (Liying Zhou and Kangle Guo)
performed title screening and data extraction of retrieved
studies, and any conflicts were resolved through discus-
sion between the two. We used the EndNote X9.1 soft-
ware to omit duplicates. Then, according to the inclusion
and exclusion criteria, the two reviewers screened the titles
and abstracts to discard irrelevant publications. Publica-
tions were removed from further review if both reviewers
excluded them. Otherwise, the full articles were obtained for
review. As a further safeguard, the full texts of the remaining
literature were read and assessed for inclusion eligibility.
We extracted the following data from the included pub-
lications using a pre-specified data form: publication date,
name of the first author, study country/region, patient char-
acteristics (such as the number of patients per group, and
disease and surgery types), and details of the intervention
(such as digital or analog drainage system, number of chest
tube placements, whether suction was used or not, and the
criteria for the removal of the drainage system). Moreover,
we extracted data on the main results, including duration of
chest tube placement, length of hospital placement, number
of chest tube clamping tests and complications (incidence
of a postoperative air leak and cardiopulmonary complica-
tion rate).
Assessment of risk of bias
The Cochrane risk of bias tool was used to evaluate the
quality of RCTs, which was based on randomization and
allocation concealment (selection bias), blinding of the per-
sonnel and participants (performance bias), blinding of the
outcome assessment (detection bias), incomplete outcome
data (attrition bias), selection of the reported results (report-
ing bias) and sources (other bias) through a low, high, or
unknown risk of bias [22]. If discrepancies arose, the two
reviewers deliberated among themselves until a consensus
was reached.
Certainty assessment
The two reviewers independently rated the certainty of evi-
dence using the “Grades of Recommendation, Assessment,
Development, and Evaluation” (GRADE) system [23]. The
GRADE approach uses five domains, including risk of bias,
inconsistency, indirectness, imprecision, and publication
bias, which are assessed to determine the degree of confi-
dence in the estimate of effect or association derived from
the meta-analysis. The quality of evidence was graded as
high, moderate, low, or very low. Any discrepancy between
3
the two reviewers was resolved through discussion. The
GRADE pro was used to import data from Review Manager
5.4.1 to create “Summary of finding” tables.
Data synthesis and analysis
Dichotomous variables were, including the occurrence of
prolonged air leak, number of chest tube clamping tests, and
cardiopulmonary complication rate, were evaluated by risk
ratio (RR) and 95% confidence interval (CI). In addition,
mean and standardized mean difference (MD and SMD,
respectively) with a 95% CI based on the inverse variance
method was used as a summary statistic of continuous vari-
ables (duration of chest tube placement and length of hospi-
tal stay). Heterogeneity was evaluated using the Higgins I2
value, and values <25, 25 to 50, and >50 were considered to
indicate low, moderate, and high heterogeneity, respectively.
Risk ratio (RR), MD, and SMD values, and the correspond-
ing 95% CIs were calculated. P < 0.05 was considered to
indicate statistical significance. All the statistical analyses
were performed using the Review Manager 5.4.1 software
(Cochrane Collaboration’s Information Management Sys-
tem) and Stata version 15.1 software (STATA, College Sta-
tion, TX, United States). Subgroup analysis was performed
on the basis of study type, and sensitivity analysis was per-
formed on the outcome indicators of ≥10 studies to explore
their potential sources and assess the robustness of these
results, respectively. The Egger’s test was used to assess for
publication bias [22].
Results
Study selection
As shown in Fig. 1, initially, 4608 studies were retrieved
from the databases. Among them, 1454 duplicate studies
were removed, and 3129 articles were excluded after read-
ing the titles and abstracts. Of the remaining 25 articles, 13
were excluded after reading the full texts. Thus, 12 studies
[19, 24–34] were included in this meta-analysis.
Main characteristics of the RCTs
The included 12 studies involved 2000 patients (985 and
1015 in the digital and traditional groups, respectively). All
the trials compared the digital chest drainage system with
the traditional chest drainage system following pulmonary
resection. Sample size largely varied among the studies
and ranged between 64 and 381. The publication years of
the articles largely varied as well, ranging between 2008
and 2021. The publications were mainly obtained from
13
4 General Thoracic and Cardiovascular Surgery (2023) 71:1–11

− 15
− 20
− 20
− 10
− 20
− 15
− 15
− 20
Level of suc-

–
0
0
0

− 15
− 20
− 20
− 10
− 20
− 15
− 15
− 15
− 20
tion

−5
−8
D

–
1–2 (24Fr/28Fr)
2 (24Fr&28Fr)
1–2 (28Fr)

1 (28Ch)
1 (24Ch)

1 (28Fr)
1 (28Fr)
1 (24Fr)
2 (28Fr)
NCT

NA
NA
NA
Mera Sucuum MS-008EX

Sherwood glass bottles

Pleur Evac A-6002-08

Sahara S-11000
Analog system

Water–sealed
Water–sealed
Water–sealed
Water–sealed
Water–sealed

Atrium Oasis
Thora-Seal
Express

D, digital drainage system; T, traditional drainage system; NCT, number of chest tubes; NA, not available; Fr, French; Ch, Charriere.
Digital system

Drentech
Drentech
Drentech
Digivent
Digivent

ATMOS

Thopaz
Thopaz
Thopaz
Thopaz
Thopaz
Thopaz
Fig. 1  Flow diagram of the literature screening process and results

Anatomic pulmonary resection

Anatomic pulmonary resection
Anatomic pulmonary resection
Anatomic pulmonary resection
European, American, and Asian countries and only consisted
of RCTs (Table1).

Pulmonary resection
Pulmonary resection
Pulmonary resection
Pulmonary resection

Risk of bias
Surgery type

Lobectomy
Lobectomy
Lobectomy
Lobectomy

A summary of the risk of bias assessment is fully reported

in Fig. 2. In general, the risk of bias was high in all the
studies analyzed. In the random sequence generation

Lung disease
Lung disease
Lung disease
Lung disease
Lung disease
Lung disease

assessment, 11 RCTs were rated to have a low risk of bias

Lung cancer
Lung cancer
Lung cancer

as they used a computer-generated randomization sched-

Disease

ule. One trial did not describe the method of randomiza-

NA
NA
NA

tion and so we judged them to have an unclear risk of bias.

Table 1  The essential characteristics of the included studies

In the allocation concealment, 7 trials clearly concealed

Sample size

115
108
164
190

32
85
45
50
49
77
50
50

the allocation using sealed opaque envelopes, and thus we

T

considered these trials to be at a low risk of bias. 3 trials

107
135
191

32
87
94
50
50
49
82
55
53

provided no information on the allocation concealment,

D

thus we judged these trials to be at a unclear risk of bias.

Denmark
Country

Allocation was not concealed in the remaining 2 trials,

Canada
Canada
Canada

Poland
Japan
USA

Italy
Italy
Italy
Italy
Italy

which we thus considered to be a high risk of bias. In all

the RCTs, the participants or personnel were not blinded
to the interventions in accordance with the nature and aims
2013
2015
2021
2017
2018
2017
2008
2010
2014
2009
2014
2017
Year

of the interventions, and thus we considered all 12 trials to

be at a high risk of bias in the performance bias domain.
Bertolaccini

Takamochi

Chiappetta

Regarding the outcome assessment, 6 trials were rated to

Mendogni
Lijkendijk

Marjańsk
Cerfolio
Brunelli
Pompili

Plourde

Gilbert

be at a “low risk of bias” because chest roentgenograms

Waele
Study

were used to check for air leaks even though assessors

were not blinded. However, 6 trials were rated to be at
a “high risk of bias” as the corresponding researchers
12
11
10
9
8
7
6
5
4
3
2
1

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General Thoracic and Cardiovascular Surgery (2023) 71:1–11
Fig. 2  Risk of bias assessment for the 12 included studies
decided on the removal of the chest tubes by observing
the air bubbles in the water seal during coughing, and this
approach is prone to inter-observer error. All of the RCTs
were found to have a “low risk of bias” in the complete
outcome data and selective reporting as they all conducted
detailed and adequate analyses and reported results for all
the outcome measures mentioned either in their protocols
or in the methods section of studies where a protocol was
not available. Regarding “other bias,” 2 RCTs received
device sponsorship from pharmaceutical companies, and
thus we considered these trials to be at a low risk of bias.
Additionally, 4 RCTs provided no information on the
funding, and thus we considered these trials to be at an
unclear risk of bias. The reminding 6 trials were rated to
have a “low risk of bias”. As for the certainty assessment,
the certainty of the evidence was low, mainly because of
the high heterogeneity among the studies (inconsistency),
wide confidence intervals (imprecision), and the risk of
bias (Table 2).
5
Meta‑analysis results
Duration of chest tube placement
A total of 11 studies, with the digital and traditional chest
drainage systems applied to 953 and 983 individuals,
respectively, reported the duration of chest tube placement
(Fig. 3). Patients with the digital systems had statistically
significantly shorter chest tube placement durations than
those with the traditional systems (SMD =  − 0.34; 95%
CI =  −0.51 to − 0.18; I2 = 68.7%; P < 0.001). The subgroup
analysis of the different types of surgery also showed simi-
lar results. Furthermore, the results showed that no hetero-
geneity in the subgroup of lobectomy (SMD =  −0.21; 95%
CI =  −0.40 to − 0.03; I2 = 0.0%; P < 0.05). The sensitivity
analysis showed that no single study significantly affected
overall heterogeneity.
Length of hospital stay
A total of 10 studies, with the digital and traditional
chest drainage systems applied to 895 and 868 patients,
respectively, measured the length of hospital stay (Fig. 4).
Patients who were on a digital chest drainage system
had significantly shorter hospital stays than those on a
traditional system (MD =  −0.79 days; 95% CI =  −1.24
to − 0.34; I2 = 89.8%; P < 0.001). The subgroup analysis of
the different types of surgery also showed similar results.
The results showed that no heterogeneity in the subgroup
analysis of lobectomy (MD =  −0.95 days; 95% CI =  −1.53
to − 0.37; I2 = 0.0%; P < 0.001). The sensitivity analysis
showed that no single study significantly affected overall
heterogeneity.
Occurrence of a prolonged air leak
Of the 12 studies, 5 reported the occurrence of PAL
(defined as a persistent air leak for ≥5 days) (Fig. 5). No
statistically significant difference in the occurrence of
PAL was observed between the two groups (RR = 0.74;
95% CI = 0.36 to 1.49; I 2 = 41.2% P = 0.147). Subgroup
analysis of the different types of surgery also showed simi-
lar results, and we observed lower heterogeneity in the
subgroup of lobectomy (RR = 1.06; 95% CI = 0.26–4.24;
I2 = 30.0%; P = 0.937).
Cardiopulmonary complication rate
Three studies assessed the effect of the digital drainage
system on the rate of cardiopulmonary complications
(Fig. 6). The difference between the effects of the digital
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6 General Thoracic and Cardiovascular Surgery (2023) 71:1–11

Table 2  Summary of findings

The digital drainage system compared to the traditional drainage system for patients after pulmonary resection
Patient or population: patients after pulmonary resection
Setting: hospital
Intervention: the digital drainage system
Comparison: the traditional drainage system
Outcomes Anticipated absolute e­ ffects* (95% CI) Relative effect (95% No of participants Certainty of the
CI) (studies) evidence (GRADE)
Risk with the Risk with the digital Comments
traditional drainage drainage system
system

Duration of chest tube – SMD 0.34 lower (0.51 – 1936 (11 RCTs) ⨁⨁◯◯ ­Lowa,b
placement lower to 0.18 lower)
Length of hospital stay – SMD 0.48 lower (0.77 – 1727 (10 RCTs) ⨁⨁◯◯ ­Lowa,b
lower to 0.19 lower)
Occurrence of pro- 85 per 1,000 63 per 1,000 (30 to OR 0.72 (0.33 to 1.57) 1112 (5 RCTs) ⨁⨁◯◯ ­Lowa,c
longed air leak 127)
Cardiopulmonary com- 192 per 1,000 155 per 1,000 (81 to OR 0.77 (0.37 to 1.58) 432 (3 RCTs) ⨁◯◯◯ Very
plication rates 273) ­lowa,b,c
Chest tube clamping 366 per 1,000 65 per 1,000 (39 to OR 0.12 (0.07 to 0.20) 609 (3 RCTs) ⨁⨁◯◯ ­Lowa,b
test 103)

CI, confidence interval; OR, odds ratio; SMD, standardized mean difference
GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect
Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there
is a possibility that it is substantially different
Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect
Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of
effect
*
The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect
of the intervention (and its 95% CI).
a
Downgraded once for serious study limitations: most trials had unclear/high risk of bias in blinding
b
Downgraded once for inconsistency due to moderate heterogeneity (I2 > 45%)
c
Downgraded once for imprecision due to wide confidence intervals

and the traditional drainage systems on the rate of car- Publication bias
diopulmonary complications is unclear. (RR = 0.82; 95%
CI = 0.48–1.39; I2 = 40.2%; P = 0.188). A funnel plot based on Egger’s test revealed no publication
bias (P = 0.683) (Fig. 8).

Chest tube clamping test

Three studies reported the number of chest tube clamping
tests (Fig. 7). Digital chest drainage could significantly
lower the number of clamped chest tubes (RR = 0.12;
95% CI = 0.02 to 0.76; I2 = 77.9%; P = 0.011). Subgroup
analysis of anatomic pulmonary resection showed no sta-
tistically significant difference between the two groups. In
addition, high heterogeneity was found in the subgroup of
anatomic pulmonary resection (RR = 0.11; 95% CI = 0.01
to 0.76; I2 = 87.8%; P = 0.011).
Discussion
Summary of the main results
We identified 12 published RCTs, involving a total of 2000
patients who have undergone pulmonary resection, from
Canada, Denmark, Italy, Japan, Poland, and the USA. Our
meta-analysis showed that compared with the traditional
drainage management, the digital drainage system sig-
nificantly decreased the duration of chest tube placement,

13
General Thoracic and Cardiovascular Surgery (2023) 71:1–11
Fig. 3  Duration of chest tube placement
Fig. 4  Length of hospital stay
length of hospital stay, and number of chest tube clamp-
ing tests. However, there was no significant difference in
the occurrence of a pronged air leak and cardiopulmonary
complication rates. Our results were similar to the results
of previously published meta-analyses and indicated that
the digital chest drainage system could effectively shorten
chest tube placement duration and length of hospital stay
[18]. This result can be explained by the fact that the digital
chest drainage system, unlike the analog system, can provide
7
Fig. 5  Occurrence of prolonged air leak
Fig. 6  Cardiopulmonary complication rate
information on the effectiveness of chest tube changes in
real-time without the need for a physician to be at the bed-
side. The digital chest drainage system measures the extent
of air leakage objectively, and the data can be exported and
reviewed. Continuous digital measurement of air leakage
reduces the degree of variability in air leak score, gives more
assurance for tube removal, and reports air leaks without the
apprehension of inter-observer error. The digital evaluation
of air leak removes unnecessary operational inefficiency and
reduces the number of chest radiographs required, and the
duration of chest tube placement and length of hospital stay
are consequently reduced. Our results also indicated that
the application of the digital drainage system significantly
reduces the number of chest tube clamping tests. Since the
analog chest drainage system is subjective and inaccurate
in judging air leakage, there is a risk of removing the chest
tube prematurely, which necessitates reinsertion of the chest
tube. The clamping test has traditionally been used to pre-
vent this error. Takamochi et al. have suggested that ≥50%
of the patients in the traditional group are subjected to this
test before removing the chest tube is removed, whereas no
clamping test was needed in the digital group. Additionally,
Gilbert et al. have shown that no chest tube reinsertion is
13
8 General Thoracic and Cardiovascular Surgery (2023) 71:1–11
Fig. 7  Chest tube clamping test
SND standard normal deviation
Fig. 8  Egger’s publication bias plot for assessing publication bias of
local control
needed in the digital group, unlike in the traditional group,
in which the tube reinsertions worsened the cases of pneu-
mothorax or subcutaneous emphysema.
We observed significant heterogeneity in the duration of
chest tube placement, length of hospital stay, occurrence of
prolonged air leak, incidence of postoperative air leak, num-
ber of chest tube clamping tests, and cardiopulmonary com-
plication rate. These outcomes may have been affected by
various factors. When subgroup analysis was conducted by
surgery type, duration of chest tube placement, length of hos-
pital stay, and number of chest tube clamping tests showed
no heterogeneity in the subgroup of lobectomy. This may
be due to differences in anatomical location and size among
various pulmonary resection procedures, resulting in differ-
ent duration of air leakage. The homogeneity of the included
studies may also have been affected by the involvement or
13
level of suction. For example, the Intervention of digital
group also included a continuous suction of −15 cm ­H2O,
whereas the traditional drainage system simply uses gravity
and a single chamber of 370 ml water seal, with no possi-
bility of applying external suction. In contrast, patients on
some digital chest drainage systems are connected to the
pump at −20 cm H ­ 2O immesiately after extubating until the
morning of the first postoperative day (POD), and then the
suction is turned off (0 cm ­H2O). Patients with traditional
devices are connected to wall suction (−20 cm ­H2O) until
POD 1 and then disconnected. The difference in the criteria
of chest tube removal for digital or analog chest drainage
system between the included studies may have been a source
of heterogeneity. For example, Brunelli et al. [19] have stipu-
lated that if the average air leak flow is 0 ml ­min−1 during
the last 6 h, a chest X-ray should be obtained, and the pleural
effusion threshold for removal was 400 ml ­day−1, if the lung
was deemed sufficiently expanded, the chest tube of digital
chest drainage system was removed. As for the analog chest
drainage system, the pleural effusion threshold for removal
was 400 ml ­day−1, if no air leak was detected in this way in
the morning or evening rounds, a chest X-ray was obtained.
The chest tube was removed if the lung was deemed suffi-
ciently expanded at the chest X-ray. However, Cerfolio et al.
[28] have stipulated that chest tubes are removed when the
output is ≤ 450 ­cm3 ­day−1 and there is no discernible air leak
in either system. The same criterion for chest tube removal
was applied to both groups of patients. In short, there were
no uniform criteria for the removal of chest tubes in these
included studies.
In 2018, Zhou et al. [21] performed a systematic review
and meta-analysis evaluating the safety and effectiveness of
the digital versus analog chest drainage system in the post-
operative management of patients with lung disease, includ-
ing pneumothorax, following pulmonary surgery. However,
General Thoracic and Cardiovascular Surgery (2023) 71:1–11
the results showed that the difference between the effects of
between the two chest drainage systems is inclusive with
respect to occurrence of PAL and the percentage of patients
discharged home on a device. In addition, the authors
pointed out that further studies are needed. The heterogene-
ity of the types of lung disease (including lung cancer and
spontaneous pneumothorax) and surgery (including all types
of pulmonary surgery) precluded a meaningful interpretation
of the results Zhou et al. In 2019, another meta-analysis, per-
formed by Wang et al. [18], compared the efficacy of the two
systems in patients with lung disease following pulmonary
resection. Their meta-analysis included only 5 RCTs and 3
observational studies, and the authors pointed out that fur-
ther RCTs with larger sample sizes are still needed to clarify
the advantages of the digital drainage system. We also chose
to include patients with lung disease following pulmonary
resection and exclude patients with spontaneous pneumo-
thorax, which does not require pulmonary resection. Our
meta-analysis included 7 new trials in addition to the ones
analyzed by Wang et al., and we selected only RCTs that
compared the digital drainage system with the traditional
drainage system. These trials were conducted in different
countries, increasing the generalizability of the results.
Quality of evidence
The results of this meta-analysis should be interpreted with
caution, even though they are based on rigorously designed
RCTs. In our assessment, a high risk of bias existed in
the blinding of the participants and outcome assessment.
Although some of the studies included in our assessment
implemented complete randomization and allocation con-
cealment, none of the participants or outcome assessors of
the studies was blinded. The assessors on duty made deci-
sions on whether to remove the chest tube based on the
information acquired from the traditional or digital device
and according to different predetermined criteria. The pos-
sibility of a systematic bias in the postoperative manage-
ment of patients across the digital and traditional groups
cannot be ruled out entirely. In general, the present results
should be interpreted by considering these differences and
the relatively high heterogeneity. It is challenging to blind
the participant to the intervention and to avoid impacts of
these differences on the credibility of the results. How-
ever, 6 studies used chest X-rays to ensure the reliability of
the outcome assessment. Furthermore, the remaining five
domains were at a low risk of bias, with only a few trials at
a high or unclear risk of allocation concealment bias or other
bias. Therefore, taking all this into consideration, we rated
the overall quality of the evidence as low. As illustrated in
Table 2, the summary of finding for the main comparison
reflected that the quality of the body of evidence for each
outcome ranged from low to very low. The main results for
9
downgrading the quality of evidence were high heterogene-
ity between the risk of bias, inconsistency, and imprecision.
The main limitation of this review is the low certainty of
the available evidence due to concerns regarding the risk
of bias (downgrade one level for all outcomes) and due to
imprecision-wide confidence intervals (downgrade one level
for the outcomes on the duration of chest tube placement,
length of hospital stay, cardiopulmonary complication rates
and chest tube clamping test), and due to the statistical het-
erogeneity between trials (downgrade one level for the out-
come on cardiopulmonary complication rate).
Limitations
This study has some limitations. First, the patients, health-
care staff, and investigators involved in the studies could
not be blinded to the study due to the intrinsic nature of
the intervention. They all knew which device was applied
because of the significant differences in size and function
between the analog and digital drainage systems. The pos-
sibility of a systematic bias in the postoperative manage-
ment of the patients across the treatment and control groups
cannot be ruled out entirely. Moreover, after treatment, the
differences in types of the digital and analog drainage sys-
tems, level of suction, and criteria for chest tube removal
among the RCTs make the data heterogeneous. In addition,
the statistical indicators of continuous variable outcomes are
different between included studies, including hazard ratio,
median and interquartile range, mean and standard devia-
tion. Additionally, this meta-analysis did not include all of
the 12 studies for every analyzed dichotomous variable out-
come parameter investigated. For instance, only 5 studies
contained information about the occurrence of prolonged
air leakage, and just 3 studies contained information about
the incidence of postoperative air leaks, number of chest
tube clamping tests and cardiopulmonary complication rate.
Finally, this is a secondary study, and differences in the orig-
inal data cannot be controlled for, including experimental
design, inclusion criteria, and the original study, cannot be
controlled for, which may affect the reliability of the results.
Future research
Cost-efficiency is a vital requirement for a novel drain-
age system. The cost and features of system may influence
patients to choose one type of system rather than another
based on the performed pulmonary resection, the practice of
the surgeon in charge, and especially, the clinical course of
the patient. However, the cost difference between the digi-
tal and the traditional drainage systems was not assessed
in most of the RCTs. Despite the advantages of the digital
13
10
drainage system concluded in this study, it is still unclear
how much the equipment will cost compared to the cost-sav-
ing it offers, especially for patients who just have an air leak
POD 1. Therefore, a well-planned cost analysis (including
fixed and variable costs) that considers many factors, such as
the costs of disposable devices, treatment for postoperative
complications, hospitalization, and the healthcare system
of the corresponding country should be performed. Addi-
tionally, the economic impact of the digital system and the
hurdles in the use of this system in routine clinical practice
should be evaluated.
Our assessment revealed a substantially high risk and
unclear bias in the included RCTs due to the possibility of
some potential bias in the postoperative bedside assessment
and clinical management of patients in the treatment and
control groups because the study participants, healthcare
staff, investigators, and outcome assessors were not blinded
to patient allocation. Therefore, future research should try
to implement blinding.
We observed significant heterogeneity in most of the out-
comes. However, our results showed that the duration of
chest tube placement, length of hospital stay, and chest tube
clamping test showed no heterogeneity in the lobectomy
group when subgroup analysis was performed by surgery
type (including lobectomy, anatomic pulmonary resection,
and any type of pulmonary resection). These types of het-
erogeneity increase variance, which disguises the effects.
Surgery types varied widely, but few RCTs examined how
surgery may differentially affect the outcomes. Thus, the cur-
rent review is limited in its ability to describe the effects of
special surgery types. Differences in anatomical location and
size among various surgery types and the overall health of
patients may contribute to variable effects. Future research
would benefit from explicitly examining and describing how
surgery type relates to observed effects. A large-scale ran-
domized study that is limited to patients undergoing one
type of pulmonary resection surgery, such as lobectomy or
segmentectomy, is warranted to elucidate the effects of the
digital versus traditional thoracic drainage systems in this
population.
Conclusions
The digital chest drainage system is beneficial to patients
who have undergone pulmonary resection, in reducing the
duration of chest tube placement, length of hospital stay,
and number of chest tube clamping tests. There is no sig-
nificant difference between the two drainage systems in the
occurrence of PAL or cardiopulmonary complication rate.
Future research should evaluate the requirements and eco-
nomic impact of using the digital system in routine clinical
practice.
13
General Thoracic and Cardiovascular Surgery (2023) 71:1–11
Acknowledgements Thanks to Shuya Ni, a PhD student from Jinan
University, for her help at various stages of this review. This work
was supported by the National Natural Science Foundation of China
(72074103); the Fundamental Research Funds for the Central Universi-
ties (lzujbky-2021-ct06, lzujbky-2021-kb22); and the Gansu Special
Project of Soft Science (20CX9ZA109).
Authors’ contribution L.Z. provided research topics and ideas, and
completed the drafting; K.G. provided technical support and some
methodological guidance; X.S., E.F., M.X., and Y.W. provided part of
the data analysis. All authors discussed the results and commented on
the manuscript. All authors involved in manuscript writing and final
approval of manuscript.
Declarations
Conflict of interest All authors have completed the ICMJE uniform
disclosure form. The authors have no conflicts of interest to declare.
Ethical statement The authors are accountable for all aspects of the
work in ensuring that questions related to the accuracy or integrity of
any part of the work are appropriately investigated and resolved.
Reporting checklist We present the following article in accordance
with the PRISMA reporting checklist.
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