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.
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.
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?
I’ve been somewhat old school when it comes to chest tubes. Unlike some, I don’t believe that you have any control of where a chest tube goes if you are placing it in a closed chest. Only in the OR with an open one. And I’ve got plenty of x-rays to prove it.
And I used to think that chest tube size mattered when dealing with hemothorax. In theory, you need a big tube to get clots out, right?
Well, maybe not! The trauma group at the University of Arizona Tucson has previously done work on using 14 French pigtail catheters in lieu of a full-size tube. They will be presenting their extended experience with this concept at EAST 2017.
They have maintained a prospectively collected database of information on trauma patients with chest tubes for many years. This study focused only on those who had blood in their chest, either hemothorax (HTX) or hemopneumothorax (HPTX). They also looked at trends in their selection of chest drain tubes.
Here are the factoids:
Nearly 500 patients were treated with a tube for HTX or HPTX during the 7 year study period, 2/3 with a chest tube and 1/3 with a pigtail
Pigtails had more fluid drain initially (430cc vs 300cc, significant), and 1 less treatment day (4 vs 5, also significant)
Failure rate and insertion-related complications were the same (about 22% and 6%, respectively)
The group found that their use of pigtails steadily and significantly increased over the years
Bottom line: I’m coming around. The literature does appear to be tilting toward smaller tubes, and this longer-term study helps confirm that. How can this be? Although this is speculation on my part, it probably has to do with the fact that any size tube will drain liquid blood. And probably no size of tube will successfully get all the clot out.
And certainly, smaller tubes are much better tolerated and do not require the degree of sedation that a mega-tube does. The authors suggest that a multi-center trial should be carried out to confirm this. For my part, I’m going to review the literature we have to date and consider modifying my own chest tube policy (see links below).
Questions and comments for the authors/presenters:
Where did you typically insert the pigtails? Anterior chest or classic chest tube position? Was it consistent?
Was/is the selection of tube type an attending surgeon specific choice, or did you implement a policy to direct them?
Did patient injury pattern or body habitus have any part in tube selection?
What about removal failures? That is, how many had to have a tube replaced, and how many went on to require VATS or other surgical procedure for drainage?
Reference: A prospective study of 7-year experience of using percutaneous 14-French pigtail catheter for traumatic hemothorax at a Level I trauma – size still does not matter. Quick Shot #4, EAST 2017.
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