Drainology Symposium at AATS 2026
Summary from symposium “Advances in Air Leak Management and Drainage Systems in Pulmonary, Thoracic and Cardiac Surgery” at the AATS Annual Meeting, Chicago, IL on 3 May 2026.
The Medela sponsored Drainology Symposium at AATS 2026 brought together international experts in thoracic, pulmonary, and cardiac surgery to highlight how digital drainage systems and quantitative air leak monitoring are transforming pleural space management. Across specialties, speakers emphasized a shift away from subjective, analog assessments toward objective, data‑driven decision‑making. Presentations suggested how digital air leak quantification may improve localization and treatment of persistent air leaks using bronchoscopic techniques, safely enable earlier chest tube removal, support ERAS pathways, and extend expert‑level care beyond specialized centers. Importantly, clinical and health‑economic data indicated that while digital systems may have higher upfront costs, they can reduce complications, shorten length of stay, optimize resource utilization, and ultimately deliver cost‑effective, patient‑centered care through multidisciplinary and technology‑enabled collaboration.
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Key messages
- Digital drainage systems enable precision medicine: Quantitative air leak and fluid monitoring improves clinical decision‑making, supports targeted interventions, and enhances safety compared with traditional analog systems.
- Efficiency must be balanced with safety: Defined airflow thresholds and observation periods allow earlier chest tube removal while minimizing air leak recurrence, supporting ERAS principles across cardiothoracic care.
- Value extends beyond outcomes: Digital systems are associated with fewer complications, reduced resource use, and favorable cost‑effectiveness, with future potential amplified by AI‑driven clinical decision support.
Clinical Applications of Endobronchial Valves and Digital Air Leak Measurement in Pulmonary Care
Kai E. Swenson, MD – Beth Israel Deaconess Medical Center, Boston, USA
Dr. Kai Swenson presented an interventional pulmonology perspective on the evolving management of persistent and prolonged air leaks (PALs), emphasizing close collaboration with thoracic surgery and the emerging role of quantitative digital chest drainage.
He reviewed the changing epidemiology of PALs, noting that while most post‑biopsy, post‑traumatic, and post‑resection air leaks are self‑limited, a clinically significant minority persist. The traditional definition of PAL as an air leak lasting more than five days stems from historical postoperative length‑of‑stay benchmarks and may be outdated given modern recovery pathways. Etiologies include bronchopleural fistulas and alveolopleural fistulas, the latter particularly common in patients with emphysema or severely diseased parenchyma.
Bronchoscopic management strategies were outlined, including visual inspection, saline bubbling, dye instillation, and sequential balloon occlusion to localize leaks. Therapeutic options range from airway stents and occlusive substances to one‑way endobronchial valves, especially for distal alveolopleural fistulas. A major limitation remains collateral ventilation, which can markedly reduce the effectiveness of segmental or lobar occlusion, as demonstrated in a prior study[1].
A central focus of the talk was the integration of digital chest drainage systems to allow real-time, quantitative measurement of air leak flow during bronchoscopy. Compared with subjective assessment of bubbling, digital quantification allows clearer discrimination of segmental and lobar contributions, supports more targeted valve placement, and may help identify patients unlikely to benefit from bronchoscopic therapy.
An illustrative case of a COPD patient with a postoperative PAL showed how digital measurements guided effective lobar valve placement, leading to rapid resolution, chest tube removal, and early discharge. Dr. Swenson concluded by describing an ongoing multicenter feasibility study evaluating whether quantitative assessment improves decisionmaking and outcomes.
Emerging Trends and Clinical Outlook in Drainage and Air Leak Monitoring
Sébastien Gilbert, MD – University of Ottawa, Canada
Dr. Sébastien Gilbert provided a comprehensive overview of current challenges and emerging solutions in chest tube management, focusing on the paradigm shift enabled by digital pleural drainage systems and objective air leak monitoring. He emphasized that while over one million patients annually in North America require chest tubes, the principal gap in care lies not in tube insertion or device availability, but in consistent, high‑quality management of the pleural space, particularly air leaks and fluid drainage.
Importantly, patients undergoing lung cancer surgery represent only a small proportion (~6%) of all patients undergoing chest tube drainge. While these patients can still benefit from clinical decision support to optimize postoperative chest tube management, the vast majority require chest drainage for other conditions, often in settings without ready access to thoracic surgery expertise. These patients may stand to benefit even more from standardized, objective approaches to chest tube management and bedside clinical decision support enabled by digital drainage systems.
He contrasted traditional analog systems (based on subjective interpretation of bubbling) with continuous, quantitative digital monitoring. Studies from his group demonstrated poor interobserver agreement with analog systems, compared with excellent agreement using digital devices[2]. This objectivity supports major practice changes, including safe chest tube removal despite low‑level ongoing air leaks, provided predefined airflow thresholds and observation periods are met (e.g., <30 ml/min for 8 hours).
Dr. Gilbert presented extensive data exploring the balance between safety (air leak recurrence) and efficiency (earlier tube removal). Analysis of millions of data points showed that observation time, particularly around 8 hours, is a key determinant of safety, while flow thresholds can be moderately liberalized without excessive risk[3]. He also discussed quantitative approaches to fluid drainage, favoring physiologic, patient‑specific thresholds and demonstrating that short‑interval output can reliably estimate 24‑hour drainage[4].
Finally, Dr. Gilbert outlined future directions, including integration of artificial intelligence. He introduced CheLSEA, an AI‑based clinical decision support system designed to synthesize pleural space data and provide removal or maintenance recommendations. Early clinical evaluation showed high safety and accuracy[5]. He concluded that digital pleural monitoring, combined with decision support, offers significant potential to standardize care, improve outcomes, and extend expert‑level management beyond specialized centers.
Cost-effectiveness of Analog vs. Digital Drainage Systems in Cardiac Surgery
Johannes Petersen, MD – University Medical Center Hamburg-Eppendorf (UKE), Germany
Dr. Johannes Petersen addressed the growing economic pressures on healthcare systems and examined the cost‑effectiveness of digital versus conventional analog chest drainage systems in cardiac and thoracic surgery. He framed chest drainage management as an integral component of enhanced recovery after surgery (ERAS), with direct implications for complications, length of stay, and resource utilization.
Drawing on data from the randomized INCREASE trial[6], Dr. Petersen highlighted that ERAS protocols in cardiac surgery significantly reduce ICU and overall hospital stay while maintaining postoperative functional outcomes. Economic analyses from this work demonstrated cost savings of up to €1,900 per patient, largely driven by shorter ICU and ward stays, despite modest increases in physiotherapy costs. Earlier discharge was also discussed in the context of potentially increasing institutional capacity to treat additional patients within a given timeframe[7].
A key contributor to prolonged hospitalization after cardiac surgery is retained blood syndrome, which is associated with inflammation, atrial fibrillation, infections, renal dysfunction, and increased mortality[8]. ERAS guidelines emphasize maintaining chest tube patency to prevent this syndrome[9]. Evidence from comparative studies, including propensity‑matched analyses, suggests that digital drainage systems are associated with reductions in postoperative atrial fibrillation, ICU stay, re‑thoracotomy rates, and other drainage‑related complications[10].
Dr. Petersen reviewed health economic models from the UK (NICE[11] and the York Health Economics Consortium[12]), showing that although digital systems such as Thopaz incur higher upfront costs, these are offset by reductions in length of stay, staff monitoring time, imaging, and reinterventions. Modeled savings reached up to $1 million annually for large cardiac programs and even higher for combined cardiac–thoracic units. Additional benefits included potential reduction of waste generation and improved workflow efficiency.
Finally, German real‑world data combining clinical trial outcomes[13] with hospital billing records confirmed lower costs related to X‑rays and re‑thoracotomies with digital systems, despite similar lengths of stay[14]. Dr. Petersen concluded that digital drainage systems represent a cost‑effective strategy within modern perioperative care, while emphasizing the need for further prospective economic evaluations tailored to institutional contexts.
References
[1] Majid A, Kheir F, Sierra-Ruiz M, et al. Assessment of fissure integrity in patients with intrabronchial valves for treatment of prolonged air leak. The Annals of Thoracic Surgery. 2019;107(2):407-11.
[2] McGuire AL, Gilbert S et al. Prospective evaluation of interobserver reliability in the assessment of pulmonary air leaks. Interact CardioVasc Thorac Surg 2015:1–5.
[3] Alayche M, Gilbert S et al. Determining optimal air leak resolution criteria when using digital pleural drainage device after lung resection. JTCVS Open. 2024;18:360-368.
[4] Azzi J, Gilbert S et al. Early Identification of Patients Who Will Meet 24-Hour Fluid Output Threshold for Chest Tube Removal After Lung Resection Semin Thorac Cardiovasc Surg 2019;31(4):861-867.
[5] Arora N, Klement W, Japkowicz N, et al. Chest Tube Learning Synthesis and Evaluation Assistant (CheLSEA): A Prospective Observational Trial of an Intelligent Decision Support System. Innovations. 2026:15569845261425605.
[6] Petersen J, Stock S, Brettschneider C, et al. Interdisciplinary and Cross-Sectoral Perioperative Care Model in Cardiac Surgery: ERAS Implementation in the Setting of Minimally Invasive Heart Valve Surgery (INCREASE) – Results of a Randomized Controlled Trial. EJCTS.2026;68(2):ezag061.
[7] Petersen J, Kloth B, Konertz J, e tal. Economic impact of enhanced recovery after surgery protocol in minimally invasive cardiac surgery. BMC Health Services Research. 2021;21(1):254.
[8] Balzer F, von Heymann C, Boyle EM, et al. Impact of retained blood requiring reintervention on outcomes after cardiac surgery. JTCVS. 2016;152(2):595-601.
[9] Engelman DT, Ben Ali W, Williams JB, et al. Guidelines for perioperative care in cardiac surgery: enhanced recovery after surgery society recommendations. JAMA surgery. 2019;154(8):755-66.
[10] Kalisnik JM, Zujs V, Zibert J, Batashev I, et al. The impact of a chest drainage system on retained blood-associated complications after cardiac surgery. EJCTS. 2025;67(Supplement_1):i9-17.
[11] Evans JM, Ray A, Dale M, et al. Thopaz+ portable digital system for managing chest drains: A NICE Medical Technology Guidance. Appl Health Econ Health Policy 2019;17(3):285–94.
[12] York Value calculator; YHEC Medela Thopaz+ Chest Drain Model – FINAL – 31.07.25.xlsm. Data on file Medela.
[13] Van Linden A, Hecker F, Courvoisier DS, et al. Reduction of drainage-associated complications in cardiac surgery with a digital drainage system: a randomized controlled trial. J Thorac Dis 2019;11(12):5177-5186.
[14] Manuscript in preparation. Cost-effectiveness study of a digital drainage system: insights from a randomized clinical trial.