Tag Archives: chest tube

Chest Tube Repositioning – Final Answer

So you’re faced with a chest tube that “someone else” inserted, and the followup chest xray shows that the last drain hole is outside the chest. What to do?

Well, as I mentioned, there is very little written on this topic, just dogma. So here are some practical tips on avoiding or fixing this problem:

  • Don’t let it happen to you! When inserting the tube, make sure that it’s done right! I don’t recommend making large skin incisions just to inspect your work. Most tubes can be inserted through a 2cm incision, but you can’t see into the depths of the wound. There are two tricks:
    • In adults with a reasonable BMI, the last hole is in when the tube markings show 12cm (bigger people need bigger numbers, though)
    • After insertion, get into the habit of running a finger down the radiopaque stripe on the tube all the way to the chest wall. If you don’t feel a hole (which is punched through the stripe), this will confirm that the it is inside, and that the tube actually goes into the chest. You may laugh, but I’ve seen them placed under the scapula. This even looks normal on chest xray!
  • Patients with a high BMI may not need anything done. The soft tissue will probably keep the hole occluded. If there is no air leak, just watch it.
  • If the tube was just put in and the wound has just been prepped and dressed, and the hole is barely outside the rib line, you might consider repositioning it a centimeter or two. Infection is a real concern, so if in doubt, go to the next step.
  • Replace the tube, using a new site. Yes, it’s a nuisance and requires more anesthetic and possibly sedation, but it’s better than treating an empyema in a few days.

Chest Tube Repositioning – Part 2

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.

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

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 in my next post!

Does Chest Tube Size Matter? Part 3

So far, I’ve looked at the only two papers in the trauma literature that examine the question of chest tube size for hemothorax. As you may recall, both were woefully underpowered. Finding no difference in a study without enough subjects does not infer that the two interventions have the same results. It simply means that a (much) better study needs to be done.

One of these papers admitted that more work needed to be done, the other did not. And the one that admitted no weaknesses has been quoted by some of the pigtail catheter studies I am reviewing this week as supporting their hypothesis. They are using it as the rationale that even small catheters might work. Hmm, faulty premises?

After reviewing the pigtail for hemothorax literature since the beginning of time, I found exactly two papers that address the issue. And really, it’s just one. The first one published in 2012 was the initial series. The numbers were expanded over the following years by the same authors, and the new data was published in 2017. Of interest, the authors cite their own early paper as supporting the effectiveness of using a pigtail catheter, even though it can’t due to very low numbers Let’s dig in.

This one comes from the group a the University of Arizona in Tucson. They prospectively collected data on pigtail catheter insertions from 2008 to 2014. The outcomes studied included initial drainage output, catheter complications, and failure rate (incomplete drainage requiring another intervention).

Tubes and pigtails were placed by attending physicians or residents. Patient selection was at the discretion of the attending surgeon. The total patient group was analyzed, and then it was split into emergent placement vs non-emergent placement. Here are the factoids:

  • A total of 307 chest tubes and 189 pigtails were placed; pigtail usage increased over the study period
  • Pigtail catheter patients were older overall, especially in the non-emergent group (this was admitted as selection bias in the paper)
  • Initial output was higher in the pigtail group and reached statistical significance in the emergent placement group (500 cc vs 250 cc)
  • Pigtail insertion complications trended higher for all patients and in the non-emergent group, but not in the emergent placement group (??)
  • Failure rates were not different across the groups

The authors state the their study “clearly demonstrates favorable outcomes in pigtail catheter usage.” But does it?

Bottom line: Once again, this is a completely underpowered study. The pigtail results would need to be 2-3 times better than chest tube results to show any statistical significance. But they are not. So being non-inferior doesn’t mean anything with such small numbers. However, if you properly power a study that shows no differences, then they truly are equivalent. But with the work available to date, you can’t just run out and start using pigtails because they are “as good as” chest tubes. 

There were a few statistically significant differences in this study, but again this is clouded by other design problems. The emergent group had significantly more initial output through the pigtails. This is odd from a fluid dynamics point of view. How do you get more of a thick liquid to drain from a tiny tube? 

One potential explanation is the ability to more accurately measure the initial output in the pigtail group. When a chest tube is inserted, there is frequently some blood loss on the bed which is difficult to estimate. But when a pigtail is inserted there is almost never any leakage. It all comes out through the tube. Could the excess pigtail drainage be accounted for by external loss during chest tube placement?

The real bottom line: There are a grand total of three published papers in the past seven years that have tried to deal with tube size in traumatic hemothorax. All of them are completely underpowered and rely on the lack of significant differences to tout that they are equivalent. The real answer is: we don’t know. This is certainly not the quality of data you want to use to change your practice. We don’t know for sure if smaller tubes and pigtails result in more retained hemothoraces or followup procedures. So buyer beware! If you choose to use small tubes or pigtails in your patients, you are in uncharted territory. The first author of the 2012 small tube paper even stated that a larger multi-center is needed. I completely agree! Meanwhile, I’ll stick to big (36 Fr) and bigger (40 Fr) for hemothorax.

Reference: A Prospective Study of 7-Year Experience Using Percutaneous 14-French Pigtail Catheters for Traumatic Hemothorax / Hemopneumothorax at a Level-1 Trauma Center: Size Still Does Not Matter. World J Surg 42(1):107-113, 2012.

Does Chest Tube Size Matter? Part 2

In my last post, I reviewed a large prospective series comparing smaller (28-32 Fr) to larger (36-40 Fr) chest tubes for management of pneumothorax. The authors did not detect any significant difference because the study was underpowered given the incidence of the adverse events examined.

Today, I’ve chosen a more recent paper that attempts to do the same thing. Interestingly, it cites the previous paper as a good example showing no differences! This one is from an emergency medicine group in Fukui, Japan. It is a retrospective review of seven years worth of patients who had a chest tube inserted for hemothorax only.

Here are the factoids:

  • Small bore tubes were 20-22 French, and large bore tubes were 28 French (huh?)
  • The tube selection was made (once again) at the discretion of the attending physician
  • Demographics and injury data from the two groups were equal
  • A total of 124 tubes were placed in 116 patients, 68 small bore and 56 large bore
  • Empyema occurred in 1% in each group
  • Retained hemothorax occurred in 2% of small tube patients and 3% of large tube patients
  • An additional tube was placed in 2% of small tube patients and 7% of large tube patients (p = 0.41)
  • Pain was not evaluated

The authors concluded that “emergent insertion of the small-bore tubes had no difference in efficacy of drainage, complications or need for additional invasive procedures.”

Bottom line: Huh? Once again we have an inferior design (retrospective review) and huge potential for selection bias (no criteria or randomization for tube size). But in this case, the tube sizes are very similar! The difference in diameter between a 20 Fr tube and a 28 Fr one is only 2.5mm! Reason #1 for no apparent differences.

For reason #2, look at the sample size. First of all, this hospital placed only 124 tubes in 7 years. That’s a one tube every three weeks. Is there that little chest trauma, or is a chunk of data missing? This sample size is less than half of that in the previous post, so the statistical power is far weaker. Look at the stats above for additional tube placement. A 3.5x change was not even close to being statistically significant. In fact, this sample size would not show a significant difference for retained hemothorax until one group had nearly 8x the number! No wonder the authors assumed there was no difference. The study was not designed in such a way that it could ever show one!

So throw this study in the trash bin, too. I’ll continue my search for a more convincing “size matters” paper in my next post.

And if you think you’ve got one, send it my way so I can have a look!

Reference: Small tube thoracostomy (20-22 Fr) in emergent management of chest trauma. Injury 48(9):1884-1887, 2017.