Chest Tube Size for Traumatic Pneumothorax

Case:

 

74 year old male was brought in by paramedics, due to a fall from a balcony. He denies any LOC. He arrived boarded and colared, with a GCS of 15 without any complaints. He has a history of Atrial Fibrillation and is on coumadin. His primary survey was intact, and on secondary survey, he has mild low midline cervical and upper thoracic tenderness. His initial chest AP shows a small apical left sided pneumothorax and his pelvis XR was negative. His CT head was negative and his CT cervical spine and Thoracic spine XR shows spinous process fractures of his C7 and T1 vertebrae. On repeat chest AP, he has a large left sided pneumothorax without any signs of pleural effusion or hemothorax. As there was no blood on the XR, this led to the team asking, "How large of a chest tube does this patient really need? Could we use a pigtail catheter?"

 

Answer:

 

Traditionally, for the treatment of these traumatic pneumothoraces, large bore chest tubes have been recommended due to concern for clot within the chest tube lumen preventing drainage. No data however are available to support theses practices, therefore several articles have been published in the past two years attempting to determine the impact of chest tube size on clinically relevant outcomes.

 

In 2012, Inaba et al published a prospective, institutional review board-approved observational study. All patients requiring open chest tube drainage within 12 hours of admission from January 2007 to Januray 2010 at a a Level I trauma center were identified and followed prospectively. Clinical demographic data and outcomes including efficacy of drainage, complications, retained hemothoraces, residual pneumothoraces, need for additioanl tube insertion, video-assisted thoracoscopy, and thoracotomy were collected and analyzed by tube size. 28-32 Fr chest tubes were considered "small chest tubes" and 36-40 Fr chest tubes were considered "large chest tubes." A total of 353 chest tubes (186 small and 167 large) were placed in 293 patients. Of the 275 chest tubes that were inserted for hemothorax, 144 were small and 131 were large. Both groups were similar in age, gender, and mechanism. However, large tubes were placed more frequently in patient was a GCS <= 8, severe head injury, a systolic blood pressure < 90 mm Hg, and Injury Severity Score <= 25.

 

No statistically significant difference in tube-related complications, including pneumonia (4.9% vs. 4.65, p = 0.282), empyema (4.2% vs. 4.6%, p = 0.766), or retained hemothorax (11.8% vs. 10.7%, p = 0.981) was found when comparing small versus large chest tubes. The need for tube reinsertion, image-guided drainaged, video-thoracoscopy, and thoracotomy was likewise the same (10.4% vs. 10.7%, p = 0.719).

 

The authors of this article concluded that the size of the chest tube did not significantly affect the outcomes tested.

 

Again, in 2012, Kulvatunyou et al published an observational study of prostpectively collected data on bedside inserted pigtail catheters in patients with traumatic hemothorax or hemopneumothorax during a 30 month period at a Level I trauma center in comparison to retrospective chest tube data. The primary outcome of interest was initial drainage output. Secondary outcomes were tube duration , insertion related complications and failure rate. A total of 36 patients received pigtail catheters and 191 received chest tubes. The mean initial output was similar between the pigtail group (560 +/- 81 ml) and the chest tube group (426 +/- 37ml). In the pigtail group, the tube was inserted later than the tube inserted in our chest tube group. Tube duration, rate of insertion related complications, and failure rate were all similar.

 

The authors of this article concluded that the 14 Fr pigtail catheters seemed to drain blood as well as large-bore chest tubes based on drainage output and other outcomes studied.

 

Study Limitations:

 

Reviewing both of these studies, there one major limitation is that the interventions were not randomized. The intervention was at the discretion of the treating physician. Also the size of the pneumothorax or the hemothorax was not described as the baseline demographics. So, each study is biased considering the physicians likely did not place pigtail catheters in patients with large hemothoraces.

 

Therefore, it is this author's belief that it is still unclear if small bore catheters are appropriate treatment for traumatic hemothoraces.

 

Case Conclusion

 

A 16 Fr left sided chest tube was inserted, repeat chest AP showed reexpansion of the lung and ultimately the patient did well with an uncomplicated hospital course and he was discharged home.

 

References:

1. Inaba et al. "Does size matter? A prospective analysis of 28-32 vs 36-40 French chest tube size in trauma." J Trauma. 2012;72:422-427.

2. Kulvatunyou et al. "14 French pigtail catheters placed by surgeons to drain blood on trauma patients: Is 14-Fr too small?" J Trauma Acute Care Surg. 2012;6: 1423-1427.

 

from Dr. Kenneth Will

 

Editor's Note:  the small bore chest tubes do not connect to the "standard" size pleurevac.  It is important to ensure an adequate connection before starting.