Short Chest Tube Water Seal Has Advantages Over Long Seal for Traumatic Pneumothorax

van Veen TE, Michetti CP, Leichtle SW, et al. Prospective Comparison of Short vs Long Chest Tube Water Seal Trial for Traumatic Pneumothorax. J Am Coll Surg. December 2025.

This prospective, multicenter observational study across 25 trauma centers included 1,394 adult patients (≥18 years) with traumatic pneumothorax undergoing a water seal trial (WST) prior to chest tube removal to compare a short [6 hour (h) ± 2 h] versus long (24 h ± 2 h) trial. The primary outcome was successful chest tube removal without reinsertion; secondary outcomes included reinsertion rates, chest tube duration, number of chest radiographs after removal, and hospital length of stay (LOS).

Among the cohorts, 328 (27.4%) had short WSTs and 1,012 (72.6%) had long WSTs. Successful removal was similar between groups (73.3% short versus 68.6% long; p = 0.250). However, short WSTs had significantly fewer chest tube reinsertions (6.3% versus 9.7%; p =0.01), shorter chest tube duration (median 3 days versus 4 days; p <0.001), fewer post-removal CXRs (median 2 versus 2 but with narrower interquartile range; p <0.001), and shorter LOS (median 7 days versus 9 days; p <0.001).

For trauma surgeons, this large prospective dataset suggests that shorter water seal trials are non-inferior to longer trials in terms of successful removal and may confer practical advantages, including reduced reinsertion rates, shorter tube dwell time, fewer imaging requirements, and reduced hospital stay without compromising safety. While the similar success rates between strategies support flexibility in practice, the association with improved resource utilization and shorter hospitalization reinforces the consideration of shorter WST durations as a default in appropriate traumatic pneumothorax cases, particularly in high-volume trauma settings where efficiency and throughput are critical.