Post-pull pneumothoraces

It is not uncommon to remove a chest tube from one of our patients only to discover that the pneumothorax has recurred on follow-up Chest X-ray.  We recently discussed if there is a way to prevent this.  Two articles were presented dealing with Post-pull pneumothoraces in trauma patients.  

The conclusion from the first paper published by the group at Virginia Commonwealth University is that, while thin patients who are younger and with penetrating chest trauma are at slightly higher risk - only thin chest wall is an independent risk factor based on logistic regression.  

The Yale group looked at pulling chest tubes at end-inspiration or end-expiration and found that there was no difference related to timing.

Our practice requires a rapid pull done with a senior resident assisting to minimize the time that the chest tube might equilibrate with atmospheric pressure.

Thin chest wall is an independent risk factor for the development of pneumothorax after chest tube removal.

Anand RJ, Whelan JF, Ferrada P, Duane TM, Malhotra AK, Aboutanos MB, Ivatury RR.   Am Surg. 2012 Apr;78(4):478-80.

The factors contributing to the development of pneumothorax after removal of chest tube thoracostomy are not fully understood. We hypothesized that development of post pull pneumothorax (PPP) after chest tube removal would be significantly lower in those patients with thicker chest walls, due to the “protective“ layer of adipose tissue. All patients on our trauma service who underwent chest tube thoracostomy from July 2010 to February 2011 were retrospectively reviewed. Patient age, mechanism of trauma, and chest Abbreviated Injury Scale score were analyzed. Thoracic CTs were reviewed to ascertain chest wall thickness (CW). Thickness was measured at the level of the nipple at the midaxillary line, as perpendicular distance between skin and pleural cavity. Chest X-ray reports from immediately prior and after chest tube removal were reviewed for interval development of PPP. Data are presented as average ± standard deviation. Ninety-one chest tubes were inserted into 81 patients. Patients who died before chest tube removal (n = 11), or those without thoracic CT scans (n = 13) were excluded. PPP occurred in 29.9 per cent of chest tube removals (20/67). When PPP was encountered, repeat chest tube was necessary in 20 per cent of cases (4/20). After univariate analysis, younger age, penetrating mechanism, and thin chest wall were found to be significant risk factors for development of PPP. Chest Abbreviated Injury Scale score was similar in both groups. Logistic regression showed only chest wall thickness to be an independent risk factor for development of PPP.

Chest tube removal: end-inspiration or end-expiration?

Bell RL, Ovadia P, Abdullah F, Spector S, Rabinovici R.

J Trauma. 2001 Apr;50(4):674-7.

BACKGROUND:

Recurrent pneumothorax is the most significant complication after discontinuation of thoracostomy tubes. The primary objective of the present study was to determine which method of tube removal, at the end of inspiration or at the end of expiration, is associated with a lesser risk of developing a recurrent pneumothorax. A secondary objective was to identify potential risk factors for developing recurrence.

METHODS:

A prospective study of 102 chest tubes in 69 trauma patients (1.5 tubes per patient) randomly assigned to removal at the end of inspiration (n = 52) or the end of expiration (n = 50).

RESULTS:

Recurrent pneumothorax or enlargement of a small but stable pneumothorax was observed after the removal of four chest tubes in the end-inspiration group (8%) and after discontinuation of three chest tubes (6%) in the end-expiration group (p = 1.0). Of those, only two tubes in the end-inspiration group and 1 tube in the end-expiration group required repeat closed thoracostomy. Multiple factors were analyzed that did not adversely affect outcome. These included patient age, Injury Severity Score, Revised Trauma Score, mechanism of injury, hemothorax, thoracotomy, thoracostomy, previous lung disease, chest tube duration, the presence of more than one thoracostomy tube in the same hemithorax, or a small (but stable) pneumothorax at the time of tube removal.

CONCLUSIONS:

Discontinuation of chest tubes at the end of inspiration or at the end of expiration has a similar rate of post-removal pneumothorax. Both methods are equally safe.

thanks to Dr. Julia Berien for providing the literature review