Suction vs Water Seal for Initial Treatment of Traumatic Pneumothorax Trial (SEAL IT): A Pragmatic Cluster-Randomized Study.

BACKGROUND: Chest tubes for traumatic pneumothorax are commonly managed with initial suction before transition to water seal, despite limited evidence supporting this practice. We hypothesized that initial water seal would reduce chest tube duration without increasing complications. STUDY DESIGN: We 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 clinician discretion. The primary outcome was initial chest tube duration. The trial was registered at ClinicalTrials.gov (NCT06688734). RESULTS: 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 vs 51 hours, p = 0.001) and shorter total chest tube duration (44 vs 60 hours, p = 0.011). Complications, secondary interventions, and mortality were similar between groups (all p > 0.05). CONCLUSIONS: Initial water seal management was associated with shorter chest tube duration without an observed increase in complications. These findings challenge routine initial suction for selected patients with traumatic pneumothorax and support evaluation of an initial water seal strategy in larger multicenter studies.