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The Answer to the Silent “Super Spreader”: An Innovative Way to Manage Chest Drains on Coronavirus Patients With Active Air Leaks

Angeles, Clara MD, MSc*; Magharious, Peter MD; Cvetkovic, Draginja MD; Weigel, Tracey MD, FACS*,‡

Author Information
doi: 10.1213/XAA.0000000000001419
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The coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has affected over 50 million people worldwide and has caused over 240,000 deaths in the United States alone. The risk of aerosol transmission has been a key factor for its rapid dissemination, since the virus can remain viable and infectious in aerosols for hours.1 Particular concern has been raised regarding the exposure of health care personnel, especially during aerosol-generating procedures. Tube thoracostomy insertion and removal is a potential aerosol-generating procedure and guidelines are implemented to minimize exposure during these procedures.2 However, little is mentioned about the chest drain management and potential risk of aerosolization during transportation of COVID-19 patients with chest drains with active air leaks. We propose an innovative mechanism to minimize the aerosolization of SARS-CoV-2 virus particles during transportation of patients perioperatively with chest drains with an active air leak.


Traditionally, chest drain systems, specifically the Atrium Ocean System, have 2 ports to allow positive pressure to escape: the suction port and the positive pressure release valve (Figure 1). If the chest tube is not attached to suction, then these ports are open to the atmosphere. When air leaks into the chest drain, it causes the fluid inside the water seal monitor to bubble, which then can escape through the suction port or the safety valve. In the setting of a COVID-19–infected patient, this may lead to viral aerosolization and potential infection transmission while the chest tube is on water seal.3

Figure 1.
Figure 1.:
Atrium Ocean Chest Drain System.

To avoid aerosolization while the chest tube is on water seal, we devised a way that involves placing an Ultipor100 viral filter on the suction port of the chest drain system in addition to sealing off the safety valve. The suction port would be covered with a device that consists of a segment of an endotracheal tube with an Ultipor100 viral filter at the end (Figures 2, 3). This viral filter has >99.99% retention of airborne bacteria and viruses while only adding 2 cm of water resistance at a flow of 60 L/min to allow air to vent avoiding the development of a tension pneumothorax. The positive pressure release valve was covered with bone wax, forcing all the positive pressure air to flow through the filter and avoiding any viral particles to be released.

Figure 2.
Figure 2.:
Atrium Ocean Chest Drain System with Ultiport100 Viral filter.

The Pall Ultipor 100 viral filter is a breathing system commonly used in anesthesia and the intensive care unit.4 It has an efficient hydrophobic membrane, proven to retain 100% of liquid-borne microorganisms. The manufacturer highly recommends the use of this filter to protect patients and staff against the risk of SARS during mechanical ventilation. From this, we have extrapolated its use to COVID-19–infected patients. In addition, the Ultipor 100 efficiently heats and humidifies ventilation gases for respiratory therapy patients, and it can be left in place for nebulizing treatments, making it resistant to fluid and moisture.4 This filter would need to be exchanged every 24 hours per patient.

This innovative mechanism would serve as a way to reduce the risk of aerosolization of SARS-CoV-2 virus particles during short periods of transportation perioperatively. On patients with air leaks, there is a risk of developing a tension pneumothorax when both the suction port and the positive pressure release valve are sealed. Using the Ultipor 100 viral filter allows air to vent while percolating potential viral particles. If the filter becomes blocked or kinked during transport, there is a low risk of developing a tension pneumothorax; patients would need to be closely monitored for this condition and the health care personnel in charge of transportation needs to be educated on this mechanism and what to do if there are any changes. As discussed with the project manager of the chest tube drain manufacturer Getinge, since the restriction to the air flow with this viral filter is minimal, the risk of developing tension pneumothorax is also very small. Awareness and education on symptom recognition are sufficient to mitigate this complication and treat it if necessary. The risks of COVID-19 infection for health care personnel and anyone in contact with the airborne viral particles would need to be balanced against the risk of a tension pneumothorax.

Infection control guidelines have only attributed aerosol transmission to a few pathogens, Mycobacterium tuberculosis (TB), Influenza, and Ebola virus, and now SARS-CoV-2 has been included,5 this mechanism could be widely utilized in patients with these other infectious diseases. The manufacturer for the Pall Ultipor 100 viral filter reports a >99.99% retention of airborne organisms, including TB.4 This would be a future application of this mechanism, which has not been tested.


Chest tubes with an active air leak when off suction vent to the surrounding environment, therefore, could potentially spread SARS-CoV-2 particles. Transportation of patients with chest tubes infected with COVID-19 with an active air leak could expose unprotected health care personnel to aerosolized viral particles. This mechanism allows positive pressure from an air leak to escape from the chest drain system while on water seal and minimizes the risk of viral dissemination. Patients would require close monitoring during transport to ensure mechanism does not become blocked.

Figure 3.
Figure 3.:
Positive pressure release valve, sealed with bone wax.


Name: Clara Angeles, MD, MSc.

Contribution: This author helped research, write, and edit the manuscript.

Name: Peter Magharious, MD.

Contribution: This author helped edit the manuscript.

Name: Draginja Cvetkovic, MD.

Contribution: This author helped edit the manuscript.

Name: Tracey Weigel, MD, FACS.

Contribution: This author helped research, write, and edit the manuscript.

This manuscript was handled by: Mark C. Phillips, MD.


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    3. Bilkhu R, Viviano A, Saftic I, Billè A. COVID-19: chest drains with air leak – the silent ‘super spreader’? 2020. doi: 10.25373/ctsnet.12089130.v1.
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