EBM Review Series: Picking the Right Chest Tube, Does Size Matter?
VACEP Evidence-Based Medicine for General Emergency Physicians Series
Authors: Navjot Kaur, DO & Martin D. Klinkhammer, MD, MPH, FACEP | Eastern Virginia Medical School at Old Dominion University
Reviewers: Hunter Williams, DO PGY-2, Winston Wu, MD | Virginia Tech Carilion
The VACEP Evidence-Based Medicine Review Series allows Virginia emergency medicine residents and attendings to share and analyze a recent peer-reviewed clinical study. You can also read the full article, “Outcomes of Pigtail Catheter Placement versus Chest Tube Placement in Adult Thoracic Trauma Patients: A Systematic Review and Meta-Analysis”, in Volume 89, Issue 6 of the American Journal of Surgery
THE CASE
A thirty-year-old male presents to the emergency department (ED) as the unrestrained driver of a rollover motor vehicle accident. During his trauma assessment, the patient becomes progressively more dyspneic, and you are unable to auscultate breath sounds on the right chest wall. A single-view chest X-ray confirms traumatic hemopneumothorax.
Do you reach for the pigtail catheter (PTC) (</=14 French) or the large bore catheter (LBC) that you were trained to place for a hemothorax (28-32 French)?
BACKGROUND
Historically, it has been surgical dogma that large bore catheters (LBC) (28-32 French) are necessary to drain hemothoraces in the setting of trauma (1). However, there have been several recent small studies that question whether large bore catheters are any more effective than smaller ones, specifically pigtail catheters (PTC) (2, 3). These studies have generally found either equal efficacy or a trend towards improved drainage when using a PTC, as compared to a LBC. Furthermore, these studies, though small, have consistently found that patients suffer less pain and discomfort from the use of PTC over LBC. This aligns with our own clinical practice, as patients receiving PTCs generally seem much more comfortable than those receiving LBCs. These studies led the Eastern Association for the Surgery of Trauma (EAST) in 2021 to conditionally recommend pigtail catheters over larger bore thoracostomy tubes for the drainage of traumatic hemothorax among hemodynamically stable patients (4). However, in that guideline, it was expressed that this recommendation was based on only 4 studies; 2 prospective observational studies, 1 retrospective observational study, and only 1 randomized controlled trial (RCT). Given this, the recommendation was conditional, non-unanimous (4/14 panel members had no recommendation) and based on low quality evidence. In practice, the decision to place a PTC vs. LBC is often guided by patient presentation, habitus, and provider experience/preference. While conceptually similar, pigtail catheters are often tolerated better from a pain management perspective (5, 6, 7). Of additional consideration are chest tube-related complications including failure, initial drainage output, hospital/intensive care length of stay (LOS), ventilator dependence, and tube duration. Since 2021, other studies have been published looking at these questions. Most recently, Beeton et al. published a systematic review and meta-analysis hoping to more definitively answer the question: for patients presenting with traumatic hemo/pneumothorax, which is the best pleural drainage option (8)?
STUDY SUMMARY:
This was a systematic review and meta-analysis of previous trials. The study authors began by asking 5 population, intervention, comparison, and outcome (PICO) type questions looking at PTCs vs. LBCs in adult patients with traumatic pneumothorax, hemothorax, or hemopneumothorax. 1) Is there a difference in failure rates? 2) Is there a difference in initial drainage output? 3) Is there a difference in either ICU-LOS or H-LOS? 4) Is there a difference in ventilator days? 5) Is there a difference in tube duration? The study population included adult (>/=18 years of age) trauma patients diagnosed with a pneumothorax, hemothorax, or hemopneumothorax who received a thoracostomy. Studies were included if the study compared outcomes associated with PTC vs. LBC. After the authors’ search for relevant studies that answered these questions, they were left with 7 eligible studies, consisting of 2 RCTs, 3 prospective studies, and 2 retrospective studies.
Chest tube failure, defined as replacement of the chest tube or requirement of a video-assisted thoracoscopic surgery (VATS) procedure, was noted to have an increased relative risk of 1.13 [95% CI: (.85-1.51)] in the standard chest tube group in comparison to the pigtail group. It is important to note that this difference was not statistically significant. The authors went on to do a sub-group analysis of those patients requiring VATS and found that the chest tube group had a significantly higher risk of requiring VATS compared to the pigtail group with a relative risk of 2.77 [95%CI: (1.50-5.11)].
Pigtail catheters were noted to have an increased initial drainage output by roughly 114.7 mL [95% CI: (70.6 mL-158.8 mL)] in the first 30 minutes in comparison to LBCs. Interestingly, there was no statistically significant difference in hospital or ICU length of stay between tube types and similarly, no difference in days on a ventilator. There was statistical significance noted in tube duration between pigtail catheters and chest tubes, with the pigtail catheter being pulled on average 0.8 [95% CI: (0.6 to 1.0)] days sooner than the LBC.
The authors conclude that in this meta-analysis comparing PTC to LBC in adult thoracic trauma patients, PTCs were found to have a significantly lower incidence of VATS, greater initial output, and a shorter overall duration compared to LBCs. Additionally, PTCs were not associated with a significant difference in failure rate, ICU-LOS, H-LOS, or ventilator days compared to LBCs.
About the EBM Review Series
This is a literature review series started by the University of Virginia’s Josh Easter, MD, MSc, a VACEP board member working to connect the academic community in Virginia. We invite each residency in Virginia (and D.C.) to create a faculty/resident team to submit and review articles. Sign up to submit one.
Goals
Provide a brief monthly synopsis of a high yield article germane to the practice of emergency medicine for distribution to all VACEP members
Provide an opportunity for a peer reviewed publication and invited presentation for faculty and trainees
Foster an academic community focused on evidenced based medicine for emergency medicine residency programs in the region
STRENGTHS AND LIMITATIONS
This is the largest available study on the use of PTCs compared to LBCs for the management of adults with traumatic thoracic injuries. While it found that VATS was significantly more likely following LBC vs. PTC, some studies included in the analysis were more likely to place LBCs in emergent settings and in patients suffering penetrating trauma, thereby possibly skewing the results to favor PTCs, as PTCs would only be used in more stable patients. These findings are in line with a previous study showing that patients with traditional chest tubes have a significantly higher risk of requiring VATS than patients with small-bore pigtail catheters (6). Nonetheless, that study is also a retrospective observation study, and as such has the same risk of confounding by indication (meaning that the reason the LBC may have been chosen was that the patient was sicker or bleeding more significantly, such that they would also be at higher risk for requiring VATS unrelated to which type of chest tube was chosen).
As was the case for the most recent EAST guidelines, the studies comparing LBCs to PTCs continue to draw from primarily 2 institutions, decreasing external validity. Additionally, it only incorporated 2 RCTs in the meta-analysis. These RCTs themselves only included 20 and 23 patients. Furthermore, there remains a paucity of literature surrounding the use of PTCs in hemodynamically unstable patients or those sustaining penetrating trauma, so no statement can be drawn about these patients from this data.
CONCLUSION
This is the largest available study on the use of PTCs compared to LBCs for the management of adults with traumatic thoracic injuries. While it found that VATS was significantly more likely following LBC vs. PTC, some studies included in the analysis were more likely to place LBCs in emergent settings and in patients suffering penetrating trauma, thereby possibly skewing the results to favor PTCs, as PTCs would only be used in more stable patients. These findings are in line with a previous study showing that patients with traditional chest tubes have a significantly higher risk of requiring VATS than patients with small-bore pigtail catheters (6). Nonetheless, that study is also a retrospective observation study, and as such has the same risk of confounding by indication (meaning that the reason the LBC may have been chosen was that the patient was sicker or bleeding more significantly, such that they would also be at higher risk for requiring VATS unrelated to which type of chest tube was chosen).
As was the case for the most recent EAST guidelines, the studies comparing LBCs to PTCs continue to draw from primarily 2 institutions, decreasing external validity. Additionally, it only incorporated 2 RCTs in the meta-analysis. These RCTs themselves only included 20 and 23 patients. Furthermore, there remains a paucity of literature surrounding the use of PTCs in hemodynamically unstable patients or those sustaining penetrating trauma, so no statement can be drawn about these patients from this data.
SOURCES
Sorino C, Feller-Kopman D, Mei F, Mondoni M, Agati S, Marchetti G, Rahman NM. Chest Tubes and Pleural Drainage: History and Current Status in Pleural Disease Management. J Clin Med. 2024 Oct 23;13(21):6331. doi: 10.3390/jcm13216331. PMID: 39518470; PMCID: PMC11547156.
Bauman ZM, Kulvatunyou N, Joseph B, Gries L, O'Keeffe T, Tang AL, Rhee P. Randomized Clinical Trial of 14-French (14F) Pigtail Catheters versus 28-32F Chest Tubes in the Management of Patients with Traumatic Hemothorax and Hemopneumothorax. World J Surg. 2021 Mar;45(3):880-886. doi: 10.1007/s00268-020-05852-0. Epub 2021 Jan 7. PMID: 33415448; PMCID: PMC7790482.
Kulvatunyou N, Bauman ZM, Zein Edine SB, de Moya M, Krause C, Mukherjee K, Gries L, Tang AL, Joseph B, Rhee P. The small (14 Fr) percutaneous catheter (P-CAT) versus large (28-32 Fr) open chest tube for traumatic hemothorax: A multicenter randomized clinical trial. J Trauma Acute Care Surg. 2021 Nov 1;91(5):809-813. doi: 10.1097/TA.0000000000003180. PMID: 33843831.
Patel NJ, Dultz L, Ladhani HA, Cullinane DC, Klein E, McNickle AG, Bugaev N, Fraser DR, Kartiko S, Dodgion C, Pappas PA, Kim D, Cantrell S, Como JJ, Kasotakis G. Management of simple and retained hemothorax: A practice management guideline from the Eastern Association for the Surgery of Trauma. Am J Surg. 2021 May;221(5):873-884. doi: 10.1016/j.amjsurg.2020.11.032. Epub 2020 Nov 17. PMID: 33487403.
Beshay M, Mertzlufft F, Kottkamp HW, et al. Analysis of risk factors in thoracic trauma patients with a comparison of a modern trauma centre: a mono-centre study. World J Emerg Surg. 2020;15(1):45. doi:10.1186/s13017-020- 00324-1 Published 2020 Jul 31.
Orlando A, Cordero J, Carrick MM, Tanner AH 2nd, Banton K, Vogel R, Lieser M, Acuna D, Bar-Or D. Comparing complications of small-bore chest tubes to large-bore chest tubes in the setting of delayed hemothorax: a retrospective multicenter cohort study. Scand J Trauma Resusc Emerg Med. 2020 Jun 22;28(1):56. doi: 10.1186/s13049-020-00754-5. PMID: 32571367; PMCID: PMC7310264.
Dull KE, Fleisher GR. Pigtail catheters versus large-bore chest tubes for pneumothoraces in children treated in the emergency department. Pediatr Emerg Care. 2002;18(4):265-267.
Beeton G, Ngatuvai M, Breeding T, et al. Outcomes of Pigtail Catheter Placement versus Chest Tube Placement in Adult Thoracic Trauma Patients: A Systematic Review and Meta-Analysis. The American SurgeonTM. 2023;89(6):2743-2754. doi:10.1177/00031348231157809
