Comparative effectiveness of suction versus water seal following tube thoracostomy in traumatic pneumothorax and hemothorax: An updated systematic review and meta-analysis

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Abstract

BACKGROUND: Tube thoracostomy is commonly used in patients with chest trauma. However, optimal management after chest tube insertion remains controversial, particularly regarding the use of suction versus water seal systems. This updated meta-analysis evaluated the comparative effectiveness of suction and water seal management in traumatic pneumothorax and hemothorax patients. METHODS: A systematic search of PubMed, Embase, Web of Science, and Cochrane CENTRAL databases was performed from database inception to May 2026. Randomized controlled trials comparing suction with water seal after tube thoracostomy were included. Risk of bias was assessed using the Cochrane RoB-2 tool, while certainty of evidence was evaluated using the GRADE approach. Clinical significance was determined using minimal clinically important difference (MCID) thresholds based on Cohen's d. RESULTS: Five randomized controlled trials involving 404 patients were analyzed. Suction significantly reduced chest tube duration (MD: -2.95 days; 95% CI: -4.58 to -1.31; p = 0.0004) and hospital length of stay (MD: -3.98 days; 95% CI: -5.70 to -2.27; p < 0.00001) compared with water seal management. Suction also improved rates of full lung expansion (OR: 4.86; 95% CI: 1.70-13.88; p = 0.003). MCID analysis demonstrated clinically meaningful benefits for hospital stay, chest tube duration, and lung expansion. No significant differences were found in recurrent pneumothorax, re-intervention rates, or retained/clotted hemothorax between groups; however, these findings remain inconclusive due to the small number of studies, which may have lowered the statistical power to detect any meaningful differences. CONCLUSION: Suction appears to improve hospital stay, chest tube duration, and lung expansion following tube thoracostomy in traumatic chest injuries. However, these findings should be interpreted cautiously as all the included trials were at high risk of bias, primarily due to the lack of clinicians, participants, and outcome assessors blinding, which may have influenced subjective outcomes such as chest tube removal and hospital discharge. Therefore, well-designed randomized trials are required to strengthen the certainty of evidence.

Abstract as published, via PubMed.