Category Archives: Thorax

Conventional Chest Tube vs Pigtail Catheter

Traditionally, hemothorax and pneumothorax in trauma has been treated with chest tubes. I’ve previously written about some of the debate regarding using smaller tubes or catheters. A paper that will be presented at the EAST meeting in January looked at pain and failure rates using 14Fr pigtail catheters vs 28Fr chest tubes.

This was a relatively small, prospective study, and only 40 of 74 eligible patients were actually enrolled over 20 months at a Level I trauma center in the US. Pain was measured using a standard Visual Analog Scale, as was complication and failure rate, tube duration and hospital stay.

The following interesting findings were noted:

  • Chest wall pain was similar. This is expected because the underlying cause of the pneumothorax, most likely rib fractures, is unchanged.
  • Tube site pain was significantly less with the pigtail
  • The failure rate was the same (5-10%)
  • Complication rate was also the same (10%)
  • Time that the tube was in, and hospital stay was the same

Bottom line: There may be some benefit in terms of tube site pain when using a smaller catheter instead of a chest tube. But remember, this is a very small study, so be prepared for different results if you try it for your own trauma program. If you do choose to use a smaller tube or catheter, remember to do so only in patients with a pure pneumothorax. Clotted blood from a hemothorax will not be completely evacuated.

Reference: A prospective randomized study of 14-French pigtail catheters vs 28F chest tubes in patients with traumatic pneumothorax: impact on tube-site pain and failure rate. EAST Annual Surgical Assembly, Oral paper 12, 2013.

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Trauma Chest Tube Tips

I’ve written a lot about chest tubes, but there’s actually a lot to know. And a fair amount of misinformation as well. Here’s some info you need to be familiar with:

  • Chest trauma generally means there is some blood in the chest. This has some bearing on which size chest tube you choose. Never assume that there is only pneumothorax based on the chest xray. Clot will plug up small tubes.
  • Chest tubes for trauma only come in two sizes: big (36Fr) and bigger (40Fr). Only these large sizes have a chance in evacuating most of the clot from the pleural space. The only time you should consider a smaller tube, or a pigtail type catheter, is if you know for a fact that there is no blood in the chest. The only way to tell this is with chest CT, which you should not be getting for diagnosis of ordinary chest trauma. Having said this, there is some more recent literature that suggests that size might not matter as much as we think.
  • When inserting the tube, you have no control of the location the tube goes once you release the instrument used to place it. Some people believe they can direct a tube anteriorly, posteriorly, or anywhere they want. They can’t, and it’s not important (see next tip).
  • Specific tube placement is not important, as long as it goes in the pleural space. Some believe that posterior placement is best for hemothorax, and anterior placement for pneumothorax. It doesn’t really matter because the laws of physics make sure that everything gets sucked out of the chest regardless of position except for things too big to fit in the tube (e.g. the lung).
  • Tunneling the tube tract over a rib is not necessary in most people. In general, we have enough fat on our chest to ensure that the tract will close up immediately when the tube is pulled. A nicely placed dressing is your insurance policy.
  • Adhere to an organized tube management protocol to reduce complications and the time the tube is in the chest.

And finally, amaze your friends! The French system used to size chest tubes is the diameter of the tube in millimeters times three (3.14159, pi to be exact). So a 40Fr chest tube has a diameter of 13.3mm.

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Coming This Week: Chest Tube Week

I’m dedicating the coming fortnight (that’s two weeks to you non-Brits) to the lowly chest tube. It’s taken for granted, but there is a lot a variability on how we insert, manage, and pull out these devices. Here’s what’s coming, starting tomorrow:

  • Videos on how to insert a chest tube and pigtail catheter
  • A video on how to pull a chest tube properly
  • Chest tube tips and tricks
  • A practice guideline for chest tube management
  • Troubleshooting chest tubes
  • Collection systems gone bad
  • Lateral chest x-ray for pneumothorax: waste of time?
  • When to remove a chest tube
  • Autotransfusing blood from the collection system

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Retained Hemothorax Part 4: The Practice Guideline

Over the last three days, I reviewed some data on lytics at the request of some of my readers. Then I looked at a paper describing one institution’s experience dealing with retained hemothorax, including the use of VATS. But there really isn’t much out there on how to roll all this together.

Until now. The trauma group at Vanderbilt has a paper in press describing their experience with a home-grown practice guideline for managing retained hemothorax.  Here’s what it looks like:

I know it’s small, so just click it to download a pdf copy. I’ve simplified the flow a little as well.

All stable patients with hemothorax admitted to the trauma service were included over a 2.5 year period. The practice guideline was implemented midway through this study period. Before implementation, patients were treated at the discretion of the surgeon. Afterwards, the practice guideline was followed.

Here are the factoids:

  • There were an equal number of patients pre- and post-guideline implementation (326 vs 316)
  • An equal proportion of each group required an initial intervention, generally a chest tube (69% vs 65%)
  • The number of patients requiring an additional intervention (chest tube, VATS, lytics, etc) decreased significantly from 15% to 9%
  • Empyema rate was unchanged at 2.5%
  • Use of VATS decreased significantly from 8% to 3%
  • Use of catheter guided drainage increased significantly from 0.6% to 3%
  • Hospital length of stay was the same, ranging from 4 to 11 days (much shorter than the lytics studies!)

Bottom line: This is how design of practice guidelines is supposed to work. Identify a problem, typically a clinical issue with a large amount of provider care variability. Look at the literature. In general, find it of little help. Design a practical guideline that covers the major issues. Implement, monitor, and analyze. Tweak as necessary based on lessons learned. If you wait for the definitive study to guide you, you’ll be waiting for a long time.

This study did not significantly change outcomes like hospital stay or complications. But it did decrease the number of more invasive procedures and decreased variability of care, with the attendant benefits from both of these. It also dictates more selective (and intelligent) use of additional tubes, catheters, and lytics. 

I like this so much that I plan to adopt it at my center!

Download the practice guideline here.

Related posts:

Posts in this series:

Reference: Use of an evidence-based algorithm for patients with traumatic hemothorax reduces need for additional interventions. J Trauma, in press, December 14, 2016.

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