Initial Water Seal May Shorten Chest Tube Duration After Traumatic Pneumothorax

Yeates EO, Dennis BM, Xiao D, Vimalathas P, et al. Suction vs Water Seal for Initial Treatment of Traumatic Pneumothorax Trial (SEAL IT): A Pragmatic Cluster-Randomized Study. J Am Coll Surg. September 2026.

Chest tubes for traumatic pneumothorax are commonly managed with initial suction before transition to water seal, despite limited evidence supporting this practice. Yeates and colleagues hypothesized that initial water seal would reduce chest tube duration without increasing complications.

The authors conducted a single-center, pragmatic, month-based cluster-randomized study of adult trauma patients with pneumothorax requiring chest tube placement from October 2024 to May 2025. Patients with a hemothorax component >300 mL or chest tube placement before computed tomography were excluded. Patients were assigned by alternating calendar month to initial suction or water seal; subsequent management was at the clinician’s discretion. The primary outcome was initial chest tube duration. The trial was registered at ClinicalTrials.gov (NCT06688734).

Among 3,372 trauma admissions, 133 patients required chest tubes for pneumothorax, and 72 met inclusion criteria (37 suction, 35 water seal). Four patients died before chest tube removal and were excluded from the primary outcome analysis. Initial water seal was associated with shorter median initial chest tube duration compared with suction (41 versus 51 hours, p = 0.001) and shorter total chest tube duration (44 versus 60 hours, p = 0.011). Complications, secondary interventions, and mortality were similar between groups (all p > 0.05).

Initial water seal was associated with shorter chest tube duration without an observed increase in complications. These findings suggest initial water seal may be an alternative to routine suction for selected patients with traumatic pneumothorax and support evaluation in larger multicenter studies.