Yesterday, I went over the rationale for developing a practice guideline for something as simple and lowly as chest tube management. Today, I’m posting the details of the guideline that’t been in use at my hospital for the past 15 years. I’ve updated it to reflect two lessons learned from actually using it.
Here’s an image of the practice guideline. Click to open a full-size copy in a new window:
Here are some key points:
Note the decision tree format. This eliminates uncertainty so that the clinician can stick to the script. There are no hedge words like “consider” used. Just real verbs.
We found that hospital length of stay improved when we changed the three parameters from daily monitoring to three consecutive shifts. We are prepared to pull the tube on any shift, not just during the day time. And it also allows this part of the guideline to be nursing driven. They remind the surgeons that criteria are met so we can immediately remove the tube.
Water seal is only used if there was an air leak at some point. This allows us to detect a slow ongoing leak that may not be present during our brief inspection of the system on rounds.
The American College of Surgeons Committee on Trauma expects trauma centers to monitor compliance with at least some of their guidelines. This one makes it easy for a PI nurse or other personnel to do so.
The first of the “new” parts of this guideline is: putting a 7 day cap on failure due to tube output greater than 150cc per three shifts. At that point, the infectious risks of keeping a tube in begin to outweigh its efficacy. Typically, a small effusion may appear the day following removal, then resolves shortly.
The second “new” part is moving to VATS early if it is clear that there is visible hemothorax that is not being drained by the system. Some centers may want to try irrigation or lytics, but the data for this is not great. I’ll republish my posts on this over the next two days.
Management of chest tubes is one of those clinical situations that are just perfect for practice guideline development: commonly encountered, with lots of variability between trauma professionals. There are lots of potential areas for variation:
How long should the tube stay in?
What criteria should be used to determine when to pull it?
Water seal or no?
When should followup x-rays be done?
Every one of these questions will have a very real impact on that patient’s length of stay and potential for complications.
We developed a chest tube clinical practice guideline (CPG) at Regions Hospital way back in 2004! Of course, there was little literature available to guide us in answering the questions listed above. So we had to use the clinical experience and judgment of the trauma faculty to settle on a protocol that all were comfortable with.
Ultimately, we answered the questions like this:
The tube stays in until three specific criteria are met
The criteria are: <150 cc drainage over 3 shifts, no air leak, and no residual pneumothorax (or at least a small, stable one)
Use of water seal is predicated on whether there was ever an air leak
An x-ray is obtained to determine whether any significant pneumo- or hemothorax is present prior to pulling the tube, and 6 hours after pulling it
This CPG has been in effect for over 15 years with excellent results and dramatically shortened lengths of stay. However, as with any good practice guideline, it needs occasional updates to stay abreast of new research literature or clinical experiences. We recognized that occasional patients had excessive drainage for an extended period of time. This led us to limit the length of time the tube was in to seven days. And we also noted that a few patients had visible hemothorax on their pre-pull imaging. These patients were very likely to return with clinical symptoms of lung entrapment, so we added a decision point to consider VATS at the end of the protocol.
I’ll share the full protocol tomorrow and provide a downloadable copy that you can modify for your own center. I’ll also give a little more commentary on the rationale for the key decision points in this CPG.
I love stuff about chest tubes. There are so many opinions and so little data to back them up. And now here’s another EAST 2019 Annual Assembly paper from the University of Arizona at Tucson on chest tubes! The traditional dogma, and something that I’ve promoted for some time, is that the only size chest tube that should be used for hemothorax is big (36 Fr) or bigger (40 Fr). There have been a few abstracts and published papers over the past 7 years that are trying to change this assumption. Will they be successful?
The first work on this was a paper published in 2012 by this same group in Tucson. It was a prospective study that included 36 patients with pigtails and 191 with 32 Fr – 40 Fr chest tubes over 30 months. Average initial drain output was the same, and there were no differences in tube in time, complications, or failure rate.
A related abstract was then presented by this group at the 2013 EAST Annual Assembly, but it doesn’t look like this one got published. It was a small, prospective study that enrolled 40 of 72 eligible patients over 20 months and compared pigtail catheters vs 28 Fr chest tubes. They found that chest wall and tube site pain was less with a pigtail, and that failure and complication rates, tube in time, and hospital stay were the same.
And then in 2017 more related work was presented at EAST from the group, and was later published in the World Journal of Surgery. This study was the culmination of 7 years of experience, and included nearly 500 subjects. Once again, initial drainage output was the same, as were complications and failure rate. The authors concluded that a multi-center trial was need to provide additional support.
And that brings us up to EAST 2019. Now the authors are presenting a single-center study comparing 14 Fr pigtail vs 28-36 Fr chest tubes for hemothorax and pneumthorax. What’s different about this one? For the first time, the subjects were randomized between pigtail and chest tube in an effort to eliminate selection bias.
Here are the factoids:
A total of 43 patients were enrolled, but the number excluded was not given
Although baseline characteristics of the two groups were identical, several differences approached clinical significance: percent blunt trauma, flail chest, insertion day, and initial chest tube output
The authors concluded that there were no differences in initial chest tube output, failure rate, tube days, and lengths of stay. However, perceived pain was less.
They again noted that a multi-center trial should be performed to confirm these results
Here are some questions for the authors and presenter to consider in advance to help them prepare for audience questions:
What’s new and different with this study? The University of Arizona – Tucson has been studying pigtails since 2009. Tell us about the progression of this work and how the current study fits in.
How many patients were excluded? This is very important, especially if this number is high. What were the exclusion criteria exactly?
What did your power analysis show? The overall enrollment numbers are low, which may throw your statistics into doubt. This is especially true since your primary outcome showed that pigtail and chest tube outputs were the same but with a p=0.06! More patients may have helped show the desired difference.
Were the pigtail and chest tube groups really “similar?” There were more penetrating injuries in the chest tube group. Could this have an impact on clotted vs non-clotted blood in the chest and the ability of a pigtail to drain it? And the median pigtail insertion date was 1.5 days later than for chest tubes, which is clinically significant. Could this allow time for defibrination of the hemothorax, resulting in better drainage?
And what’s next? Will I see you again at EAST 2020 or 2021 with a larger prospective study? Or a multi-center one?
I’m looking forward to hearing this one in person!
A single center prospective randomized study comparing the effectiveness of 14 French percutaneous catheters (pigtail) versus 28-36 French chest tube in the management of traumatic hemothorax/hemopneumothorax. EAST 2019 Paper #13.
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.
Yesterday I presented the problem of the malpositioned chest tube, specifically one that is not completely in the pleural space. This one is wayout:
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
Tomorrow, I’ll finish this series and provide some tips and guidelines to help manage this problem using the principles outlined above.
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