From Research to Clinical Practice
How the Innovation May Improve the
Thoracic Surgeon’s Skill
Cosimo Lequaglie
Dpt. of Thoracic Surgery
IRCCS-CROB Cancer Center
Rionero in Vulture, ITALY
Nowsadays: the evolution...
Surgical technique is evolved and
the available means can allow an
effective and safe postoperative
chest drainage.
The digital chest tube airflowmeter AIRFIX®
TEUP’s Ltd., Deutshlandsberg, A, 2002
“A data acquisition system digitizes the output signal of a “mass airflow sensor”
and continuously sends measurement values to a processor. Only the “netto” flux
into one direction is recorded as air-leak. The amount of air moving into the
opposite direction (shift of intrapleural dead space) is subtracted from the leakage.
Sensor parameters are stored in the Elettrically Erasable Memory Area (EEROM)
of a microcontroller”
Anegg U, Lindenmann J, Matzi V et al., AIRFIX®: The first digital postoperative chest tube airflowmetry –
A novel method to quantify air leakage after lung resection. Eur J Cardiothorac Surg 2006;29:867-872
Digi VentTM - Millicore AB, Danderyd, Sweden
a
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b
Controller Unit: Micro Electronic Mechanical System (MEMS) sensors providing
a digital measurement and recording of air flows (ml*min-1/l*h-1) and pressures:
maximum, minimum, differential (peMAX- piMIN) (cmH2O).
Controller single use only.

Liquid Crystal Display: showing measurement data at the bedside of the patient:
“real time” (instantaneous) flows (up) and pressures (down), 1-3-6 hours airflow
averages.
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The Controller Unit recorded data every 2 min.
TM
Digi Vent - Millicore AB,
Danderyd, Sweden
COLLECTION CHAMBER
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Canister capacity: 2000 ml
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One-way dry valve
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Pressure reducing valve
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Mechanical suction regulator
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Liter/hour air flow accumulation button
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Flashing hi/lo pressure alarm (> 5 cm H20; < - 40 cmH20)
Digi Vent
TM
– More Advantages
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The C.U. displays real time flow and pressure readings, but
the data downloaded in Excel are the last actual measured
readings in 2 minutes increments.
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The data on the Controller Unit are not erased by the
download process.
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One, three and six hours air flow averages displayed on the
C.U. just while attached to the collection chamber.
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Graph form of C.U. data images are automatically saved as
jpeg files.
a
b
Air leak in the same patient: the progressive divergent pressure curves
anticipates the visual appearance of the air leak. The curves show the expiratory
(dark blue) and inspiratory (blue) pressures. You can observe an initial interspace
among “ep” and “ip” in the first 12 post-operative hours (p.o.): after a preassure
plateau, and finally a progressive divergence of the curves from the 2nd p.o. day (a):
the superior curve (electric blue) shows the differential pressure (Δp = ep-ip); (b): the
superior curve (yellow) underlines an air leak in the first 12 hours, no leak until to the
3rd p.o. day, and a late leak anticipates from a differential pressure in increase.
Rita Daniela Marasco, Gabriella Giudice, and Cosimo Lequaglie. How to distinguish an
active air leak from a pleural space effect. Asian Cardiovasc Thorac Ann 2012;20:682-688
a
b
So-called pleural space: you can observe a great differential pressure in
a (blue electric) without air leak in b (yellow curve). Large swinging
endopleural pressures (Δp>25 cmH2O) for poor elastic serosa in
empyema and pleural effusions.
Increasing air leak
>500 ml/min
The converging curves show
the complete re-expansion of
the lung and the possibility to
remove the chest drain
a
b
Obstructed clot drain: in the same patient from the 1st p.o. day, sudden reduction of
the differential pressure (blue electric) and convergence of e.p. and i.p. curves in low
(dark blue and blue). a): this corresponds to the disappearance of air flow (yellow)
after an evident air leak at the beginning; b): this happens when there is an obstruction
of the chest tube, to example from clot in the drain or kinging during the night.
ATMOS E201 Thorax - MedizinTechnik,
Lenzkirch, Germany
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Measurement and recording
air flows (l/min).
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Vacuum unit on defalult
negative pressures (-5 up to 100 cmH2O).
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Rechargeable battery up to
12 hrs
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Canister capacity: 2000 ml
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Pump off mode not provided.
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Water seal valve available.
THOPAZ - Medela, Baar, CH
a
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INTELLIGENT THERAPY
OPTIMIZED CARE
The 1st digital chest drain with portable suction
pump and downloading data on board
The 1st DRENTECH® REDAX had an
adjustable vacuum control unit with a
water seal chamber and an obvious
analogue detection. In any case with a
sucking pump.
a
The DRENTECH® MOBILE REDAX had
an adjustable vacuum control unit with a
water seal chamber and an obvious
analogue detection. All time visibility for air
leak monitoring. Capacity volume 2550 ml.
Sucking pump from -10 up to -60 cmH2O.
DRENTECH® PALM REDAX
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Measurement and recording
air flows (ml/min) and
endopleural
pressures
(cmH2O), until 99 hours.
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Vacuum unit on default
negative pressures (-10 up to
-60 cmH2O).
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Pump off mode not provided.
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Water seal valve available.
Speedy passage
D
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RENTECH® PALM EVO REDAX
Detection and recording air flows
(ml/min) plus endopleural
pressures (cmH2O or KPa), until
99 hours. Mini USB-key port.
Vacuum unit on default negative
pressures (-10 up to -60 cmH2O).
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Rechargeable battery up to 36 hrs
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Pump off mode provided.
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Water seal for the collection
chamber.
Characteristics of the digital devices mostly
profits the postoperative clinical evaluation
Value of “real time” air leak (up-date every minute).
This parameter is the quantification of the bubbles that the surgeon is usual to
appraise in the box with water valve. The advantage consists in the objective
evaluation of the leak, without the usual problems owed to the subjective
interpretation of the quantity and frequency of the bubbles.
Value of the “intrapleural” pressure (measured on board) in real time.
This measurement represents the equivalent of the excursion of the meniscus in the
water valve. The pressure trend is visualized in graphic format with an oscillating
bar on the display. The variations follow the each respiratory acts of the patient.
Mean value per hour of the air leaks, adjourned every hour.
Such parameter represents an important help of evaluation because it shows a clear
and objective evaluation of the air leak, without the “trouble” of the inevitable
variations caused by many “istant” factors. These values are memorized and
revisable for 99 hours directly on PALM EVO.
Course of the air leak and the intrapleural pressure in graphic format.
This possibility is useful to appraise “to glimpse” the evolution of the 2 parameters
in the time.
Characteristics of the digital devices mostly
profits the postoperative clinical evaluation
Value of the air leaks “in real time” (up-date every minute).
This parameter is the quantification of the bubbles that the surgeon is usual to
appraise in the box with water valve. The advantage consists in the objective
evaluation of the leak, without the usual problems owed to the subjective
interpretation of the quantity and frequency of the bubbles.
Value of the “intrapleural” pressure (measured on board) in real time.
This measurement represents the equivalent of the excursion of the meniscus in the
water valve. The pressure trend is visualized in graphic format with an oscillating
bar on the display. The variations follow the each respiratory acts of the patient.
Mean value per hour of the air leaks, adjourned every hour.
Such parameter represents an important help of evaluation because it shows a clear
and objective evaluation of the air leak, without the “trouble” of the inevitable
variations caused by many “istant” factors. These values are memorized and
revisable for 99 hours directly on PALM EVO.
Course of the air leak and the intrapleural pressure in graphic format.
This possibility is useful to appraise “to glimpse” the evolution of the 2 parameters
in the time.
Characteristics of the digital devices mostly
profits the postoperative clinical evaluation
LLL: air leak: air flow ml/min
Value of the air leaks “in real time” (up-date every minute).
This parameter is the quantification of the bubbles that the surgeon is usual to
appraise in the box with water valve. The advantage consists in the objective
evaluation of the leak, without the usual problems owed to the subjective
interpretation of the quantity and frequency of the bubbles.
Value of the “intrapleural” pressure (measured on board) in real time.
 PleuralofPressures
cmH2in
O the
This measurement represents the equivalent of the excursion
the meniscus
water valve. The pressure trend is visualized in graphic format with an oscillating
bar on the display. The variations follow the each respiratory acts of the patient.
Mean value per hour of the air leaks, adjourned every hour.
Such parameter represents an important help of evaluation because it shows a clear
and objective evaluation of the air leak, without the “trouble” of the inevitable
variations caused by many “istant” factors. These values are memorized and
revisable for 99 hours directly on PALM EVO.
Course of the air leak and the intrapleural pressure in graphic format.
This possibility is useful to appraise “to glimpse” the evolution of the 2 parameters
in the time.
Because our Cancer Research Institute
testing all the “digital thoracic drains”
has chosen and modified PALM EVO
Extreme simplicity of use:
The digital drain has been inserted in the routine use with very brief “learning
curve”, both for the surgeon and the nurse. Such characteristic is facilitated
by the presence of the unidirectional water valve that allows always the
“analogical” evaluation of the leaks.
Availability of all the necessary information to the management of the patient in
postoperative period:
They are directly present and utilizable on the instrument for 99 hours (over 4
days) from the beginning of the drain. It is not necessary to effect some transfer
of the data to a PC; such possibility is optional for following elaborations
or for the recording.
It is a “true” chest drain:
Good ability of collect, water valve, handle for the transport and the fixing.
Versatility of the tool that allows, in every moment, to be able to work in
aspiration or in ”real” gravity or, even, to be connected to the aspiration
checked to wall: this is a great advantage if it is considered that the thoracic
patient can be transferred often for other diseases or complications to other
departments.
What does it mean that PALM EVO works in
“real” gravity ?
Today the devices on the market
don't allow the digital drain for
gravity, there is always a certain
aspiration. This last, to practice an
effect on the pleural cavity, doesn't
allow further the evaluation of the
excursion of
the intrapleural
pressures.
The “Pump-off ” function of the
PALM EVO allows to eliminate
whatever intervention from the
aspirant pump: the drain proceeds
completely to gravity. The air
coming from the patient is expelled
through a special valve for which
the drain is always active without
any risk for the patient.
Why to know the trend and the value
of the intrapleural pressure ?
 Pleural Pressures cmH2O
RIGHT LOWER LOBECTOMY
pulmonary (carcinomatous
expansion inabscess
the pleural
cavity.
of the lung)
The intrapleural pressure is related to the
In the traditional systems, such parameter is entirely appraisable in real time
observing the meniscus of the water in the unidirectional valve. Increased
excursions are usually related to the presence of a “ real pleural
space” in the chest, usually caused by an incomplete pulmonary
expansion. The PALM EVO device allows to appreciate the
trend of such pressures during the whole postoperative period;
the maximum and minimum pressure trend has contemporarily shown on the same
graph. In our and other colleague experience, the examination of such
trend can be predictive of the beginning of a prolonged air leak
(PAL). In every case the progressive expansion can be appreciated especially in the
cases of compromise or emphysematous pulmonary parenchyma.
Utility of the available parameters by the
digital devices ?
Superfluous complication or real aid to the
treatment of the patient ?
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As for other situations, it is not essential that the physician uses
“all and always” the available performances. The use of the PALM
EVO functions is extremely simplified and modular: the physician can
make trust on the parameters that will mostly hold profits in a particular
moment or in another situation, without necessarily consulting the
others. To example: the simplest and useful parameter is, without
doubt, the value of the hour-average air leak.
The PALM EVO doesn't result to be “intrusive”, neither it has
been planned for modifying the habits and the “modus operands”
of the physician, on the contrary to suit itself for this.
In a different context, the physician can progressively deepen the use of
the instrument making trust on the other functionalities. In this view
we can affirmed that the device is a real aid for the physician.
Why to use a “digital device”?
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The adoption of a “digital device” in the management of the
thoracic patient is of great utility since it furnishes certain
elements and “objective” to analyze the p.o. period and to
appraise the most opportune actions to undertake:

appraise the best moment for the removal of the drains
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avoiding further verifications, like the “provocative clamping”
causes of more duration of the hospital stay
best continuity results in the management of the patient (change turn of the physicians
and the nurses)
the physician has all the data that the device also picks up in his absence.
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oral narration
Today also, the physician is founded on the news during the
“examination round ward” or that he draws by the colleagues on
the medical record. A “digital device” allows to have a
“continuous” control improving the general monitoring of the
patient.
Why to employ really the digital drain
REDAX PALM EVO ?
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All the advantages before illustrated are available in simple, sure and
immediate way.
The device facilitates the physician and nurse management to
advantage of the safety of the patient (the touch screen facilitates the
consultation from the physician but, being normally off, it doesn't
influence the management from the nurses).
The device allows a complete mobility of the patient for a fast
recovery and relieving the load of job of the hospital personnel.
The PALM EVO has unique and innovative characteristics that
to today make it the available most complete system on the
market.
Finally, the cost of purchase and exercise is competitive in
comparison to other devices.
Thank you