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We thank Drs Goncalves Mendes Neto and Jabuonski for their interest and feedback on our systematic review and meta-analysis1Chang S.H. Kang Y.N. Chiu H.Y. Chiu Y.H. A systematic review and meta-analysis comparing pigtail catheter and chest tube as the initial treatment for pneumothorax.Chest. 2018; 153: 1201-1212Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar comparing pigtail catheter vs chest tube as the initial treatment for pneumothorax. We agree that drainage duration can be influenced both by external factors (eg, physicians’ decisions, hospitals’ routine practices) and internal factors (eg, lung conditions, initial severity of pneumothorax at diagnosis). Owing to the limitations of a meta-analysis, factors that affect the timing of intercostal drain removal could not be completely obtained in our study. As such, we should keep in mind that the drainage duration does not simply reflect the effect of chest tubes or pigtails but also a function of other factors as well. Intercostal drains are removed when the indication for placement has resolved. For patients with pneumothorax, the goal is to have a fully expanded lung on chest radiographs. The optimal timing for removal of intercostal drains is mainly determined by two factors: air leak and fluid production. In clinical practice, intercostal drains could be removed if there is no air leak and the fluid production is within a tolerable range. However, neither CHEST2Baumann M.H. Strange C. Heffner J.E. et al.Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement.Chest. 2001; 119: 590-602Abstract Full Text Full Text PDF PubMed Scopus (874) Google Scholar nor the British Thoracic Society3MacDuff A. Arnold A. Harvey J. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010.Thorax. 2010; 65: ii18-ii31Crossref PubMed Scopus (894) Google Scholar provide explicit recommendations concerning the timing of removal of intercostal drains, which might result in different standards on when to remove these drains. Another option is to implement digital drainage systems, which might reduce interobserver variability in air leak assessment.4Cerfolio R.J. Bryant A.S. The benefits of continuous and digital air leak assessment after elective pulmonary resection: a prospective study.Ann Thorac Surg. 2008; 86: 396-401Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar, 5Brunelli A. Salati M. Refai M. Di Nunzio L. Xiume F. Sabbatini A. Evaluation of a new chest tube removal protocol using digital air leak monitoring after lobectomy: a prospective randomised trial.Eur J Cardiothorac Surg. 2010; 37: 56-60Crossref PubMed Scopus (105) Google Scholar Regarding the comparison of drainage duration between pigtail and chest tube, only five studies were included in our meta-analysis.1Chang S.H. Kang Y.N. Chiu H.Y. Chiu Y.H. A systematic review and meta-analysis comparing pigtail catheter and chest tube as the initial treatment for pneumothorax.Chest. 2018; 153: 1201-1212Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar To minimize the impact from the external factors (eg, physicians’ decisions, hospitals’ practices), the prerequisite is to build a clear guideline, which has not reached a consensus to date. Further investigation concerning the optimal timing of removal of intercostal drains is warranted. A Systematic Review and Meta-Analysis Comparing Pigtail Catheter and Chest Tube as the Initial Treatment for PneumothoraxCHESTVol. 153Issue 5PreviewThe optimal initial treatment approach for pneumothorax remains controversial. This systemic review and meta-analysis investigated the effectiveness of small-bore pigtail catheter (PC) drainage compared with that of large-bore chest tube (LBCT) drainage as the initial treatment approach for all subtypes of pneumothorax. Full-Text PDF Pigtail Catheter vs Chest Tube as the Initial Treatment for PneumothoraxCHESTVol. 154Issue 3PreviewAs bedside ultrasound becomes synonymous with modern care of patients who are critically ill, pigtail catheters (PCs) have become increasingly common. However, head-to-head comparisons with a large-bore chest tube (LBCT) are lacking. We appreciate the work of Chang et al1 in the recent systematic review and meta-analysis in CHEST (May 2018) comparing PCs and LBCTs as the initial treatment for pneumothorax drainage and its relevance to current hospital practices. Full-Text PDF