ORIGINAL ARTICLE The Active Tube Clearance System A Novel Bedside Chest-Tube Clearance Device Shanaz Shalli, MD,* Edward M. Boyle, MD,† Diyar Saeed, MD,* Kiyotaka Fukamachi, MD, PhD,* William E. Cohn, MD, PhD,‡ and A. Marc Gillinov, MD§ Objective: Chest-tube clogging can lead to complications after heart and lung surgery. Surgeons often choose large-diameter chest tubes or place more than one chest tube when concerned about the potential for clogging. The purpose of this report is to describe the design and function of a proprietary active tube clearance system, a novel device that clears clots and debris from chest tubes. Device Description: The active tube clearance system is a novel chest tube clearance apparatus developed to maintain chest tube patency. Chest tube clearance is achieved by advancing the specially designed clearance member back and forth within the chest tube under sterile conditions, breaking down and pulling clots back toward the drainage receptacle, thereby leaving the inner portion of the chest tube clear of any obstructing material. Conclusions: By maintaining chest tube patency, chest tube drain- age can be performed more safely, and this apparatus may possibly lead to the use of smaller chest tubes and less invasive insertion techniques. Key Words: Hemothorax, Clogging, Pneumothorax, Outcome, Chest tube, Drainage, Occlusion, Thoracostomy. (Innovations 2010;5:42–47) C hest tubes are inserted in patients after heart, lung, and trauma surgery. In the setting of pneumothorax, hemotho- rax, or pericardial tamponade, chest tubes facilitate removal of blood, serous fluid, or air and prevent heart and lung compres- sion. Chest tubes commonly become partially or completely occluded with blood clots or other fibrinous material, which can impair their function. To achieve optimal outcomes in the setting of ongoing production of blood, effusions, or air, maintaining an adequately functioning chest tube is, therefore, critical. 1 Occlusion of drain tubes can lead to life-threatening com- plications, including tamponade, tension pneumothorax, and sepsis. 2,3 Additional surgery may be necessary if occluded tubes lead to development of empyema or a hemothorax that is large enough to cause loss of lung volume. 1,4,5 To avoid the afore- mentioned complications, surgeons typically use large-bore chest tubes after thoracic surgery. 6 However, large-bore tubes are associated with significant patient discomfort; furthermore, even larger tubes frequently become clogged or occluded. Patent drainage tubes are necessary not only to drain air and fluid but also to alert caregivers to internal bleeding, air leaks, and anastomotic leaks. To keep a chest tube patent, healthcare personnel often perform numerous maneuvers to clear the clog; however, none of these actions are uniformly effective, and all have significant drawbacks clinically. 7–11 These procedures include stripping, milking (squeezing the chest tube over an area of visible clot to break it up and facilitate clot removal), and fan folding (folding and bending the chest tube to break up visible clot), all of which require manipulations of the outside of tube to try to break up thick material located inside the tube. A number of clinicians have highlighted their concerns with the high negative pressures generated inside the thorax by chest tube stripping. 7,12,13 In extreme circumstances, the surgeon will disconnect the chest tube from the tubing connector and advance a suction catheter into the tube to suction it out and reopen a clogged chest tube. 14 This technique of open suction of a chest tube, although effective, has the distinct disadvantage of requiring a break in the sterile environment of the chest tube system, as well as the creation of a pneumothorax once the occluded tube is reopened. Thus, these measures are carried out only in dire situations when no other alternatives are avail- able. 15,16 In addition to being of questionable efficacy, all of the aforementioned techniques are time consuming and can distract caregivers from other important care-related tasks. A recent survey of cardiothoracic surgeons revealed that 100% of sur- geons have seen clogged chest tubes, and a majority have seen adverse patient outcomes related to chest tube clogging. 17 This survey also found that surgeons often choose to use large- Accepted for publication October 31, 2009. From the *Department of Biomedical Engineering/ND20, Lerner Research Institute, Cleveland Clinic, Cleveland, OH USA; †St. Charles Medical Center, Bend, OR USA; ‡Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX USA; and §Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH USA. Supported by the Global Cardiac Innovation Center grant and Department of Defense, United States Army Telemedicine and Advanced Technologies Research Center (TATRC) award number W81XWH-05-1-0564. This product is not cleared for use by the FDA. Disclosures: Edward M. Boyle, MD, A. Marc Gillinov, MD, and William E. Cohn, MD, have financial interests in Clear Catheter Systems (Bend, OR USA), which is developing the PleuraFlow Catheter System. Address correspondence and reprint requests to Edward M. Boyle, MD, 2200 NE Neff Rd, Suite 204, Bend, OR 97701 USA. E-mail: emb@bendcable.com. Copyright © 2010 by the International Society for Minimally Invasive Cardiothoracic Surgery ISSN: 1556-9845/10/0501-0042 Innovations • Volume 5, Number 1, January/February 2010 42