Tag Archives: chest tube

Technique

Chest Tube Repositioning – Part 2

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Yesterday I presented the problem of the malpositioned chest tube, specifically one that is not completely in the pleural space. This one is way out:

So what do the doctor books say? Well, the first thing you will discover if you try to look it up is that THERE IS NO LITERATURE ON THIS COMMON PROBLEM! There are a few papers on tubes placed in the fissure and tubes inserted into the lung parenchyma. But there are only a few mentions of tubes with holes still outside the chest.

I’ve gotten a number of comments, including “you can push them in a little”, “take it out and put in another”, and “never push them in.” Since we don’t have any science to guide us, we have to use common sense. But remember, I’ve shown you plenty of examples where something seems reasonable, but turns out to be ineffective or downright harmful.

There are three principles that guide me when I face this problem:

  • Prevention is preferable to intervention
  • Do no (or as little as possible) further harm
  • Be creative

Tomorrow, I’ll finish this series and provide some tips and guidelines to help manage this problem using the principles outlined above.

Technique

What To Do When The Chest Tube Is Not In The Right Place

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It happens from time to time. Your patient has a hemothorax or pneumothorax and you insert a chest tube. Well done! But then the xray comes back:

The last hole in the drain is outside the chest! What to do???

Here are the questions that need to be answered:

  • Pull it out, leave it, or push it in?
  • Does length of time the tube has been in make a difference?
  • Does BMI matter?

Leave comments below regarding what you do. Hints and final answers next!

Thorax

Best of AAST #6: Antibiotics For Chest Tubes??

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For as long as I can remember (nearly 50 years worth of literature) there has been some debate about giving antibiotics after chest tube insertion to decrease the infection rate. The pendulum moved back and forth for decades, never getting very far into the “give antibiotics” side. It’s been quite a while since I remember any new papers on this, and I thought the debate had been resolved in favor of never using them.

But then I see an abstract from the AAST multi-institutional trials group studying presumptive antibiotics after chest tube insertion! They conducted a prospective, observational study at 22 Level I trauma centers, enrolling nearly 2,000 patients. They matched patients in antibiotic and no antibiotic groups, arriving at (only) 272 patients in each group.

Here are the results:

Bottom line: First, it’s a little disappointing that the numbers were so low with a trial that includes 22 trauma centers. Did they have a hard time finding centers that would give antibiotics? Or was it just hard to match patients for the variables they were looking at? Regardless, there were no significant differences in infectious complications, and a non-clinically significant difference in ICU stay with antibiotics.

Why won’t this die? If there are so few papers that show an actual benefit from giving antibiotics after chest tube insertion with 50 years of data, then it’s very unlikely that it will ever be shown to be necessary!

Reference: Presumptive antibiotics for tube thoracostomy for traumatic pneumothorax. Session XXII Paper 49, AAST 2018.

General

Where Did The French Tube Size System Come From?

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Medicine sure has some weird measurement systems. Besides the more standardized units like microliters, milligrams, and International Units, we’ve got some odd stuff like French (tubes) and gauge (needles). When dealing with tubes and catheters, the size is usually specified in French units.

Where did the French system come from? It was introduced by a Swiss-born gentleman named Joseph-Frédéric-Benoît Charrière. He moved to Paris and was apprenticed to a knife maker. At the age of 17, he founded a  company that manufactured surgical instruments. His company developed and improved a number of surgical instruments, including hypodermic needles and various catheters.

Charrière introduced the system for describing catheters based on their outer diameter (OD).  It was actually named after him, and in France one will occasionally see catheters described in Ch units. Unfortunately, we Americans had a hard time pronouncing his name, and changed it to the French system (Fr).

So what’s the translation? The Ch or Fr number is the outer diameter of a catheter in millimeters multiplied by 3. It is not the outer circumference in millimeters, and the use of pi is not involved. So a big chest tube (36 Fr) has an OD of 12 mm, and a bigger chest tube (40 Fr) has an OD of 13.33 mm.

Tomorrow: Where did the needle gauge size come from?

Thorax

Chest Tubes: Size Doesn’t Matter – Part 2

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A few days ago, I wrote about a paper that seemed to suggest that using a smaller chest tube (28-32 Fr) vs larger ones (36-40 Fr). The results suggested that their function was very similar. I emphasized that I thought the result was intriguing, because I’m of the opinion that bigger is better for getting clotted blood out. However, I am amenable to changing my mind based on newer, better data.

But I did caution readers that I would like to see more data. One study should never change your practice! Then I see a lot of chatter on Twitter about another study from 2016 that looks at even smaller tubes, with people saying they will now switch to pigtail catheters (12 Fr)!!

First, not a logical progression of thinking there. And second, let’s take an actual look at the paper. It’s from an emergency medicine group in Fukui, Japan, which retrospectively reviewed their 7 year experience with using a small (20-22 Fr) vs large (28 Fr) tubes. They identified a total of 124 chest tube insertions to compare, 68 small and 56 large.

Now let’s look at the factoids:

  • Demographics, mechanism, and ISS were the same between groups
  • Duration of insertion and initial drainage were also the same between groups
  • Complication rates were similar, with 1 empyema and 2 retained hemothoraces in each group
  • Additional tubes were place in 2 patients with small tubes vs 4 with large tubes
  • Thoracotomy was performed in 2 patients with small tubes vs 1 with a large tube

Based on all of this, the authors concluded that there was no difference in drainage efficacy, complications, or need for additional invasive procedures.

Wait a minute!! Again, if you only read the abstract, you might be led to start using ever smaller chest tubes. But read the entire paper! There are many problems with this paper, including:

  • It’s a very small, retrospective review. This automatically means that the statistical power is suspect.
  • Why did they only document 124 insertions over 7 years?? That’s about one every 3 weeks! Either a lot of data are missing or they are not very busy. But Fukui Prefectural Hospital has over 1000 beds! So it’s the former, not the latter.
  • The retrospective nature means it is not possible to determine why a particular tube size was chosen. Roll of the dice? This fact alone introduces a huge potential for selection bias. Was a smaller tube selected because the hemothorax looked smaller? Probably! The fact that 4 patients with larger tubes had another one placed suggests that they were being used for larger collections. And patients with higher ISS tended to get bigger tubes.

Bottom line: Don’t change your practice based on this paper. And certainly don’t choose to use even smaller pigtails. And of course, always critically read any paper that you like to make sure you are not cherry picking the ones you choose to believe. IMHO, it’s still best to use big (36 Fr) or bigger (40 Fr).

Reference: Small tube thoracostomy (20-22 Fr) in emergent management of chest trauma. Injury 48:1884-1887, 2016.