Tag Archives: pigtail

EAST 2019 #3: Chest Tube vs Pigtail

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!

References:

  • 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.
  • EAST abstract presentation 2013.
  • EAST abstract presentation 2017.

What The Heck? Pigtail Catheter Chest Tube – The Answer

I previously described a trauma patient who had a pigtail type chest tube inserted with some odd CT findings after insertion:

So what is wrong in this picture? Well, the catheter has been inserted into the spleen! This can occur if it is inserted too low, or if there are adhesions between lung and chest wall or diaphragm.

How can it be avoided? Make sure that the insertion point is no lower than the 5th intercostal space. This is the level of the nipple in a male. And depending on what type of kit you use, be careful! Some are based on Seldinger technique, which would seem to be a bit safer. Others use a small trochar, which can be inserted a little too deeply at times. Note that this complication can occur with any kit, and can also occur when using a standard tube and open insertion technique.

Does a pigtail tube even work for hemothorax? There’s some debate about this. Traumatic hemothorax is not defibrinated like a medical one. Thus, there are frequently clots present which may not fully evacuate through a standard chest tube, let alone a tiny one. Thus, I don’t recommend a pigtail for acute traumatic hemothorax.

How should I manage this issue? Obviously, this tube needs to come out. And assuming that the initial indication for the tube is still present, a better one needs to be inserted. Dont’ pull it out yet! First, look at the vital signs. If there is significant bleeding and/or vitals are not normal, an immediate trip to the operating room is in order. In this case, the patient will likely lose their spleen.

If vital signs are stable, book both an interventional radiology suite and an OR. Or better yet, use a hybrid room. Have the radiologist obtain a baseline angiogram, and position a catheter in the main splenic artery. Incrementally remove the pigtail, hand injecting a small amount of contrast each time. If extravasation is noted at any time, the radiologist can then attempt to embolize. If selective embolization isn’t successful, then the main splenic artery should be embolized. If embolization doesn’t work, or vital signs deteriorate at any time, the surgeon should immediately proceed to laparotomy. Attempts at splenic salvage will probably not be successful.

Finally, insert a new, conventional chest tube using finger guidance. Don’t make the same mistake twice! And by the way, this works for pigtails in the liver, too. They are less likely to bleed significantly when withdrawn, and obviously the radiologist can only used selective embolization if they do.

What The Heck? Pigtail Catheter Chest Tube

Here’s a case to make you think!

A patient arrives after being t-boned in his driver side door. He complains of left sided chest and abdominal pain. Chest x-ray shows a modest left hemopneumothorax. The decision is made to insert a pigtail type chest tube, and this is carried out in your trauma bay. It is uneventful, and a small amount of blood but no air is returned. The pelvis x-ray is unremarkable

The patient is then taken to CT, where an abdomen/pelvis scan with contrast is performed. This interesting slice is noted. What the heck?!

Here are my questions:

  • What is wrong in this picture?
  • How could it have been avoided?
  • Does a pigtail chest tube work for hemothorax?
  • How should this issue be managed, and where?

I’ll address these questions in my next post, and more!

Image source: internet

How To: Insert A Small Percutaneous Chest Tube

This short (10 minute) video demonstrated the technique for inserting small chest tubes, also known as “pigtail catheters.” It features Jessie Nelson MD from the Regions Hospital Department of Emergency Medicine. It was first shown at the third annual Trauma Education: The Next Education conference in September 2015, for which she was a course director.

Please feel free to leave any comments or ask any questions that you may have.

YouTube player

Related posts:
Pigtail catheters vs regular chest tubes
Tips for regular chest tubes 

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.