Chest Tube Size Research Articles

Chest tube size selection for pleural effusion: from the perspective of thoracic surgeons and pulmonologists

ABSTRACT Background The current discourse within the thoracic surgical and pulmonological communities pertains to a contentious debate over the optimal selection criteria for thoracostomy tube diameters utilized in the management of pleural effusions. A comprehensive examination of the variables that inform the clinical decision-making paradigm for the determination of appropriate chest tube calibers is imperative to enhance patient management and elevate the prognostic results. Objectives The objective of this inquiry is to elucidate the determinants that influence thoracic surgeons and pulmonologists in their selection of chest tube size for the management of pleural effusions. Methods This cross-sectional study was based on an electronic questionnaire that was sent to the targeted populations through e-mail or a professional WhatsApp. The survey assessed the considerations of chest tube size selection as well as the respective advantages, disadvantages, and potential complications related to each size. Results The conducted study encompassed participants, with a nearly even distribution between thoracic surgeons (49.1%) and pulmonologists (50.9%). Most of these practitioners are within tertiary-level medical institutions (82.1%). A preference for small-bore chest tubes (SBCT), defined as < 14 French (Fr), was indicated by 54.8% of participants. The drawbacks associated with SBCT, such as kinking (60%) and blockage (70%), influenced the decision-making process negatively, while pain was a significant factor in the selection against LBCT (64%). Ultrasound guidance was a positive influence for the selection of SBCT (55%). Complications associated with LBCT included visceral and vascular injuries (55.7%), wound infection (45.3%), re-expansion pulmonary edema (43.3%), and subcutaneous emphysema (57.5%). In contrast, malposition was a complication more commonly associated with SBCT (49.1%). Conclusion The decision regarding chest tube size was influenced by several critical factors which included the nature of pleural effusion, the volume of pleural fluid, and potential complications specific to the size of the chest tube used.

The size paradox: An analysis of tube thoracostomy in trauma

BackgroundDebate continues over chest tube (CT) size for traumatic hemothorax (HTX) and pneumothorax (PTX). We compared CT failure and opioid use between large-bore chest tubes (LB-CT) and small-bore chest tubes (SB-CT). MethodsA retrospective study comparing trauma patients with SB-CT (≤14Fr) or LB-CT (≥24Fr) was performed. CT failure includes HTX, PTX, or empyema requiring intervention. Secondary outcomes included opioid use (MME), mortality, and favorable discharge. ResultsOf 252 patients, 65.1 ​% had SB-CT. SB-CT were older with lower ISS. Failure rate was lower for SB-CT (9.2 vs 22.7 ​%, p ​= ​0.003), as was opioid use (332 vs 767, p ​< ​0.001). In adjusted analysis there was no difference in CT failure between SB-CT and LB-CT. Subgroup analysis found SB-CT had lower total MME (234 vs 342, p ​= ​0.018). ConclusionsThis study found no major differences in CT failure or opioid use by CT size, suggesting SB-CT are a safe, and effective alternative to LB-CT in trauma.

Large-bore Chest Tube Insertion: Seldinger Technique over Two Guidewires.

Large-bore chest tube insertion is commonly performed using the trocar technique and blunt dissection; however, large-bore chest tube can cause severe visceral injury due to penetration, which is a life-threatening complication. Conversely, small-bore chest tubes can be safely inserted using the Seldinger technique; however, small-bore chest tubes are prone to blockage, especially in empyema cases. Therefore, this study aimed to demonstrate large-bore chest tube insertion using the Seldinger technique over two guidewires following image-guided puncture. We started performing large-bore chest tube insertion using the Seldinger technique over two guidewires following image-guided puncture in February 2022. Demographic data and procedural details, such as chest tube size, dilator size, procedure time, and type of image-guided puncture, of patients who underwent this procedure between February 2022 and March 2023 were retrospectively reviewed. Technical success was defined as the successful drainage of the pleural cavity. This method was used for performing ten procedures in nine patients who presented with empyema, pneumothorax, and pulmonary fistula. The insertion of a large-bore chest tube with a size ranging from 18- to 24-French was successfully performed in all cases without any complications. The median procedure time was 17.5 (first quartile-third quartile, 13.5-28.0) min. Large-bore chest tube insertion using the Seldinger technique over two guidewires may be used as an alternative to conventional methods.

Chest Tube Size Selection: Evaluating Provider Practices, Treatment Efficacy, and Complications in Management of Thoracic Trauma.

The standard for managing traumatic pneumothorax (PTX), hemothorax (HTX), and hemopneumothorax (HPTX) has historically been large-bore (LB) chest tubes (>20-Fr). Previous studies have shown equal efficacy of small-bore (SB) chest tubes (≤19-Fr) in draining PTX and HTX/HPTX. This study aimed to evaluate provider practice patterns, treatment efficacy, and complications related to the selection of chest tube sizes for patients with thoracic trauma. A retrospective chart review was performed on adult patients who underwent tube thoracostomy for traumatic PTX, HTX, or HPTX at a Level 1 Trauma Center from January 2016 to December 2021. Comparison was made between SB and LB thoracostomy tubes. The primary outcome was indication for chest tube placement based on injury pattern. Secondary outcomes included retained hemothorax, insertion-related complications, and duration of chest tube placement. Univariate and multivariate analyses were performed. Three hundred and forty-one patients were included and 297 (87.1%) received LB tubes. No significant differences were found between the groups concerning tube failure and insertion-related complications. LB tubes were more frequently placed in patients with penetrating MOI, higher average ISS, and higher average thoracic AIS. Patients who received LB chest tubes experienced a higher incidence of retained HTX. In patients with thoracic trauma, both SB and LB chest tubes may be used for treatment. SB tubes are typically placed in nonemergent situations, and there is apparent provider bias for LB tubes. A future randomized clinical trial is needed to provide additional data on the usage of SB tubes in emergent situations.

Comparison of the effect of chest tube diameter on drainage rate and tube performance in patients with pleural effusion. A cross-sectional study.

Chest tube insertion is one of the essential procedures that is performed for patients suffering from pneumothorax or pleural effusion. Choosing the best chest tube size, with maximum emptying and minimum discomfort and side effects, is one of the most important factors in patient care, while the best tube size is highly a matter of debate. In this investigation, we aimed to assess the difference between the groups with different chest tube sizes regarding the time needed for drainage, the necessity of additional invasive procedures, or pain severity. In this cross-sectional study, patients with pleural effusion, were entered into the study. patients were randomly divided into two groups based on their chest tube size: size 28 and size 32. Then, the duration of complete effusion emptying and the duration of the chest tube insertion was evaluated. According to this study, 26 (65.0%) participants were male. The duration for complete evacuation of pleural effusion varied from 3 to 10 days. The average duration of chest tube retention in the group of patients with chest tube sized 28 and 32 were 5.82, and 5.91 days, respectively; The average pain intensity in the group of patients with chest tube sized 28 and 32 were 6.71 ±1.02 and 6.48 ±1.21 units, respectively. There was no significant difference in how long the chest tube needed to stay in place to fully drain the pleural effusion. They also didn't differ significantly in the need for additional invasive procedures such as VATS, and secondary chest tube insertion. There was no notable difference for pain severity and the need for painkillers in the two groups of patients.

A Formula for the Determination of Appropriate Chest Tube Size and Length of Insertion in Children

Introduction: Chest tubes are inserted regularly in clinical practice. It is a life-saving therapeutic procedure. But there can be complications if the appropriate size or length of insertion is not considered carefully. There are charts that guide, but there is no clear mathematical relationship between the age and body surface area (BSA), and the appropriate size and length of insertion. We carried out this study to develop a formula that provides a more precise guide using the child’s age or BSA. Additionally, in the absence of a chart, the clinician can easily remember the formula to determine the most appropriate size and length.&#x0D; Patients and methods: Children aged 12 years and below who had chest tube insertion at the National Cardiothoracic Centre from July 2015 to August 2016 were retrospectively enrolled into the study. The inclusion criteria was those who had the chest tube data recorded in their notes. This was the derivative cohort. The chest tube type used was SURUCATH ULTRA®. The BSA was calculated using the Mosteller formula. The statistical analysis was performed using Microsoft excel 2013. Formulae were developed from the data of the derivative cohort, and used to determine the appropriate chest tube size and length of insertion on a validation cohort from January 2021 to April 2022.&#x0D; Results: In the derivative cohort, there were 50 children, 34.0% being males. The mean age was 4.2 ± 2.9 years. The weight ranged from 3.5 – 50 kg, the height ranged from 50 – 159 cm and the body surface area ranged from 0.2 – 1.5 m2. In the validation cohort, there were 56 children, 48.0% being males. The mean age was 4.4 ± 2.8. The weight ranged from 5 – 40 kg, the height ranged from 54 – 152 cm and the body surface area ranged from 0.3 – 1.3 m2. The outcome of the validation was good. The chest tubes functioned well and there were no chest tube-associated complications.&#x0D; The formulae obtained were S (FG) = A + 16, L (cm) = 0.3A + 3.5, S (FG) = 6B + 16, L (cm) = 3.5B + 3, where S is the size of the chest tube, A is the age in years, L is the length of insertion and B is the body surface area.&#x0D; Conclusion: A formula can be developed to guide in determining the most appropriate chest tube size and length of insertion in children, using the age and body surface area.

Use of rocuronium and sugammadex for video-assisted thoracoscopic surgery is associated with reduced duration of chest tube drainage: a propensity score-matched analysis

BackgroundWe investigated the influence of different neuromuscular blocking agents and reversal agents during anaesthesia on early removal of chest tube drainage after video-assisted thoracoscopic surgery (VATS). MethodsThis retrospective single-centre study included patients who underwent VATS after tracheal intubation under general anaesthesia. Patients received either cisatracurium and neostigmine (n=547) or rocuronium and sugammadex (n=151). Quantitative neuromuscular monitoring was used and one chest tube (size 24 Fr) was inserted. To reduce potential bias, 140 patients from each group were matched by propensity score for sex, age, body mass index and indication for VATS. Primary outcome was duration of chest tube drainage after surgery. ResultsUse of rocuronium and sugammadex was associated with a shorter duration of chest tube drainage (2 [1–2] vs 2 [1–3] days; P=0.049) and a 63% reduction in delayed chest tube removal (odds ratio 0.37; 95% confidence interval [CI]: 0.20–0.67; P=0.005). This group also had a lower incidence of postoperative atelectasis (P=0.047) and consolidation (P=0.008). Each 1 h increase in the duration of anaesthesia was associated with a 1.57-fold increase in the delayed removal of the chest tube (95% CI: 1.25–1.96; P=0.005). ConclusionsDuring general anaesthesia for VATS, compared with cisatracurium and neostigmine, use of rocuronium and sugammadex was associated with a significant decrease in the incidence of postoperative delayed removal of the chest tube, atelectasis, and pulmonary consolidation.

QUALITY IMPROVEMENT INITIATIVE TO REDUCE THE RATES OF CHEST TUBE FAILURE IN MANAGEMENT OF IATROGENIC PNEUMOTHORAX FOLLOWING CT-GUIDED LUNG BIOPSY

TOPIC: Procedures TYPE: Original Investigations PURPOSE: Iatrogenic pneumothorax following Interventional Radiology (IR) CT-guided transthoracic lung biopsy is a frequent complication with reported rates between 12-45% of which 2-15% will require thoracostomy tube placement. Recently, smaller tube sizes have been made commercially available, but it is unclear if these tubes are as efficacious and safe as larger chest tubes in the management of iatrogenic pneumothorax following lung biopsy. A previous quality assessment project at our institution demonstrated higher failure rates in chest tubes of less than 10 French (Fr). Our objective was to reduce the incidence of chest tube failure when managing iatrogenic pneumothorax after CT-guided lung biopsy via IR. METHODS: After demonstrating a failure rate in smaller bore chest tubes, we met with our interventional radiology colleagues and decided to place 10 Fr chest tubes or larger after iatrogenic pneumothorax following CT-guided lung nodule biopsies. As with our previous quality assessment project, we then retrospectively completed a chart review from January 2018 to March 2021 on all IR CT-guided lung nodules biopsied and identified cases of iatrogenic pneumothorax requiring chest tube placement and those with chest tube failure. We again defined chest tube failure as expanding pneumothorax requiring additional chest tube insertion or tension pneumothorax. RESULTS: In the pre-intervention group, there were a total of 7 chest tubes of less than 10 Fr and 5 chest tube failures in the 78 cases that required chest tube insertion (9% & 6% respectively). In the post-intervention group, no catheters smaller than 10 Fr were placed and there were no chest tube failures in the 54 cases that required chest tube insertion (0%); 6 (11%) individuals had a 10 Fr, 7 (13%) had a 12 Fr, and the remaining 41 (76%) had a 14 Fr chest tube inserted. The absence of chest tubes smaller than 10 Fr in the post-intervention group was statistically significant (p=0.02). There were no failures in the post-intervention group compared to 6% in the pre-intervention group (p=0.06). CONCLUSIONS: This analysis suggests a reduction in complication rates with the use of chest tubes 10 Fr or larger in management of iatrogenic pneumothorax from CT guided lung biopsy. This quality improvement project has demonstrated a significant change in practice habits with a trend toward reduced failure rates. A larger analysis will be needed to examine the statistical significance of reduced complications after intervention. CLINICAL IMPLICATIONS: This study demonstrated a change in practice habits toward larger sized chest tubes in the management of iatrogenic pneumothorax from CT-guided lung nodule biopsy. A larger analysis will be needed to demonstrate optimal chest tube size. DISCLOSURES: No relevant relationships by hassan Al-Balas, source=Web Response No relevant relationships by Stephen Bujarski, source=Web Response No relevant relationships by Sunjay Devarajan, source=Web Response No relevant relationships by James Ramey, source=Web Response No relevant relationships by Sarah Tuthill, source=Web Response

Chronic chest pain and paresthesia after video-assisted thoracoscopy for primary pneumothorax.

BackgroundThis study aims to identify clinical and surgical risk factors for chronic chest pain and paresthesia after video thoracoscopic surgery for primary spontaneous pneumothorax.MethodsWe retrospectively collected the data of 1,178 consecutive patients <40-years-old undergoing video thoracoscopic surgery for primary spontaneous pneumothorax in 9 Italian centers in 2007–2017. Cases with <2-month follow-up were excluded, leaving 920 patients [80% male; median age: 21 (IQR, 18–27) years] for statistical analysis. The following risk factors for chronic chest pain and chronic paresthesia were assessed by univariable and multivariable Cox regression model: age, gender, cannabis smoking, video thoracoscopy ports number, pleurodesis technique (partial pleurectomy/pleural electrocauterization/pleural abrasion/talc poudrage), chest tube size (24/28 F), postoperative chest tube stay.ResultsBlebs/bullae resection with pleurodesis was performed in 732 (80%) cases; pleurodesis alone in 188 (20%). During a median follow-up of 68 (IQR: 42–95) months, chronic chest pain developed in 8% of patients, chronic chest paresthesia in 22%; 0.5% of patients regularly assumed painkillers. Chronic chest pain was independently associated with partial pleurectomy/pleura abrasion (P<0.001) and postoperative chest tube stay (P=0.019). Chronic chest paresthesia was independently associated with pleurodesis by partial pleurectomy (P<0.001), chest tube stay (P=0.035) and 28 F chest tube (P<0.001).ConclusionsAfter video thoracoscopic surgery for primary spontaneous pneumothorax, the incidence of chronic chest pain and paresthesia was significantly lower when pleurodesis was performed by pleural electrocauterization or talc poudrage, and chest tube was removed early. A 24 F chest tube was associated with lower risk of chronic chest paresthesia.

Creation of a Custom-Length, Humeral Antibiotic Cement Spacer for Use in Treatment of Shoulder Periprosthetic Joint Infection

Periprosthetic joint infection of the shoulder is a challenging clinical situation to manage owing to the fastidious organisms often present and delayed clinical presentation. While several treatment options have been described, the mainstay of treatment remains a staged revision with the use of a humeral antibiotic cement spacer. Such spacers are commercially available or can be made by hand. When an extended humeral osteotomy is required to remove a well-fixed long stem humeral component, it may be advantageous to place an antibiotic spacer with a stem length approximately as long as the hardware being removed. This technique demonstrates creation of a custom length, humeral antibiotic cement spacer for use in treatment of shoulder periprosthetic joint infection.

EARLY CHEST TUBE INSERTION (

SESSION TITLE: New Developments in the Diagnosis and Management of Mycobacterial and Bacterial Chest Infections SESSION TYPE: Original Investigations PRESENTED ON: October 18-21, 2020 PURPOSE: Therapeutic drainage with tube thoracostomy has been shown to be a safe and effective treatment of parapneumonic pleural effusions and empyema. Previous animal studies have shown that late chest tube placement (>72 h) is deleterious compared to those animals that underwent early chest tube placement (24 or 48 h). Oftentimes, drainage options are variable between clinicians and institutions provoking a delayed chest tube placement after the diagnosis is made. In this study we aim to determine the clinical outcomes of early chest tube insertion (<24 hours) in patients with complex parapneumonic pleural effusions and empyema. METHODS: We performed a retrospective analysis of the patients diagnosed with complicated parapneumonic pleural effusions and empyema that were treated with thoracostomy at BIDMC. Patients demographics, comorbidities, antibiotic treatment duration and outcomes were recorded. Clinical outcomes such as total antibiotic duration, all-cause mortality at 30 days, and need for need for intra-pleural fibrinolytic or surgery were compared between groups. RESULTS: A total of 182 patients were identified from the analysis (Age 72 years [IQR 63-83]; Body mass index 26.3 [IQR 23.3-30.2]; 120 males [65.93%]). Ninety-two (50.55%) had thoracostomy within the first 24 h after admission. Of the total, 160 patients (87.91%) had thoracostomy with chest tube size <14 Fr. The time from admission to thoracostomy was 1 day (IQR 0-4). Patients with late chest tube insertion had an increased total antibiotic duration (34 vs 27.5 days, p=0.012) and required further treatment more frequently (22.22% vs 11.96%; p=0.05). Thirty-three (36.67%) patients required VATS on the early chest tube group compared to 37 (40.22%) in the other group (p=0.28). Regarding hospital stay, patients who underwent early chest tube insertion had shorter stays compared with the other group (9.5 days vs 14.5 days, p=<0.001). There was no significant difference in terms of all-cause mortality at 30 days between groups. CONCLUSIONS: Our study suggest that early chest tube insertion decreases hospital stay, antibiotic treatment duration and the need for additional pleural interventions. CLINICAL IMPLICATIONS: Define the optimal timing for chest tube insertion in patients with complicated parapneumonic effusion and empyema. DISCLOSURES: No relevant relationships by Ramsy Abdelghani, source=Web Response No relevant relationships by Alvaro Ayala, source=Web Response No relevant relationships by Alex Chee, source=Web Response No relevant relationships by Fayez Kheir, source=Web Response Consultant relationship with Boston Scientific Please note: $1001 - $5000 by Adnan Majid, source=Web Response, value=Consulting fee Consultant relationship with olympus Please note: $5001 - $20000 by Adnan Majid, source=Web Response, value=Consulting fee Consultant relationship with pinacle biologics Please note: $1001 - $5000 by Adnan Majid, source=Web Response, value=Consulting fee Consultant relationship with cook medical Please note: $1001 - $5000 by Adnan Majid, source=Web Response, value=Consulting fee No relevant relationships by Rachel Martinez, source=Web Response No relevant relationships by Mihir Parikh, source=Web Response No relevant relationships by Priya Patel, source=Web Response No relevant relationships by Alichia Paton, source=Web Response No relevant relationships by Juan Pablo Uribe, source=Web Response

Too Big, Too Small or Just Right? Why the 28 French Chest Tube Is the Best Size

BackgroundTube thoracostomy is a commonly performed procedure in trauma patients. The optimal chest tube size is unknown. This study measures chest tube drainage in a controlled laboratory setting and compares measured flowrates to those predicted by the Hagen–Poiseuille equation. Materials and methodsA model of massive hemothorax was created, consisting of a basin containing synthetic blood substitute (aqueous Glycerin and Xanthan gum) and a standard pleur-evac setup at −20 cm H2O suction. Flow measurements were calculated by measuring the time to drain 2L of blood substitute from the basin. Chest tube sizes tested were 20F, 24F, 28F, 32F, and 36F. Thoracostomy opening was modeled using custom built device that represents two ribs, with the distance between varied 2 to 12 mm. Flowrate increases were compared against predicted increases according to the Hagen–Poiseuille equation. Percent of predicted increase was calculated, both incremental increase and using 20F tube benchmark. ResultsAll tubes were occluded at a 2 mm thoracostomy opening. At 3 mm, 32F and 36F were occluded while smaller tubes were patent. Tubes 28F and larger exhibited high speed and consistent flowrates, even after decreasing thoracostomy opening down to 7 mm, while flowrates rapidly decreased at opening smaller than 7 mm. Smaller 24F and 20F tubes exhibited highly variable flowrates through the system. Maximum flowrates were 21.7, 36.8, 49.6, 55.6, and 61.0 mL/s for 20F–36F tubes, respectively. The incremental increase in flow ratio for increasing chest tube size was 1.69 (20F to 24F), 1.35 (24F to 28F), 1.12 (28F to 32F), and 1.10 (32F to 36F). ConclusionsThe 28F chest tube exhibited high and consistent velocity, while smaller tubes were slower and more variable. Larger tubes offered only slightly higher flowrates. The 28F is a good balance of reasonable size and high flowrate and is likely the optimal size for most clinical applications.

Predictors of outcome of pleurodesis in patients with malignant pleural effusion: a systematic review and meta-analysis

ABSTRACT Objectives Pleurodesis is an important management option to palliate breathlessness in patients with malignant pleural effusion (MPE). This systematic review aimed to examine available literature for studies investigating factors that predict pleurodesis outcome. Methods The healthcare databases advanced search (HDAS) Medline and Embase in addition to Cochrane Database of Systematic Reviews were searched on for publications reporting on pleurodesis for MPE in English language. All study types reporting previously unpublished data on predictors of pleurodesis success were included. Thirty-four studies involving 4626 patients were included in the systematic review. Results The most common pleurodesis agent used was talc which was used in 27 studies. Meta-analyses demonstrated that the strongest predictors of pleurodesis success were higher pleural fluid pH, smaller volume of effusion pre-pleurodesis and full lung re-expansion post effusion drainage. Shorter duration of tube drainage, higher pleural fluid glucose, lower LDH, and lower pleural tumor burden all seem to favor pleurodesis success, but with considerable statistical heterogeneity between studies. Available data do not suggest that chest tube size affects pleurodesis outcome. Conclusion Overall, available results are difficult to interpret due to evidence quality. Prospective studies are needed to further explore these factors. Protocol registration CRD42018115874 (Prospero database of systematic reviews)

Periprocedural Major Bleeding Risk of Image-Guided Percutaneous Chest Tube Placement in Patients with an Elevated International Normalized Ratio.

To evaluate the incidence of major hemorrhage after image-guided percutaneous chest tube placement in patients with an abnormal international normalized ratio (INR) measured before the procedure. Between January 2013 and September 2017, 49 image-guided percutaneous chest tubes were placed in 45 adult patients who had an elevated INR of greater than 1.6. Data collected included routine serum pre-procedure coagulation studies, indication for chest tube placement, insertion technique, size of chest tube, and presence of complications after drain placement. Major bleeding complications were defined using the Society of Interventional Radiology classification system. Mean patient age was 62 years (range, 22-94 years), with median American Society of Anesthesiologists score of 4. Mean INR was 2.1 (range, 1.7-3), with 21 (43%) procedures with an INR between 1.7 and 1.9, 20 (41%) procedures with an INR between 2.0 and 2.4, and 8 (16%) procedures with an INR between 2.5 and 3.0. Computed tomography guidance was used for 27 (55%) procedures; ultrasound guidance was used for 22 (45%) procedures. Median size of chest tube was 10 Fr (range, 8-14 Fr) used in 27 (55%) procedures. No major bleeding complications were observed. There was a small, significant decrease in mean hemoglobin after the procedure (mean= 0.9g/dL; P < .0001), which correlated to increasing chest tube size (P= .0269). No major bleeding complications were observed after image-guided percutaneous chest tube placement in patients with an elevated INR. Major bleeding complications in these patients may be safer than initially considered, and this study encourages the conduct of larger trials for further evaluation.

Does chest tube size matter in managing parapneumonic effusions?

This study aims to compare the ‘drainage time’: the time required to drain the effusion, with a small-bore (12F) chest tube or a conventional large-bore (20–24F) chest tube in patients with a parapneumonic effusion. Data from 54 patients with parapneumonic effusions who had chest tubes

INCIDENCE OF SMALL-BORE CHEST TUBE FAILURE IN MANAGEMENT OF IATROGENIC PNEUMOTHORAX FOLLOWING CT-GUIDED LUNG BIOPSY: A VA COHORT UNDERGOING CHEST TUBE PLACEMENT BY INTERVENTIONAL RADIOLOGY

SESSION TITLE: Interventional Pulmonary SESSION TYPE: Original Investigations PRESENTED ON: 10/08/2018 04:30 PM - 05:30 PM PURPOSE: Our objective was to define the incidence of our institution's rate of small bore chest tube failure in the management of iatrogenic pneumothorax following CT-guided transthoracic lung biopsy by IR. Additionally, we looked to further assess for any difference that exists in incidence rate based on chest tube size. Ultimately, this analysis would be utilized to potentially modify current practices to improve patient safety in those veterans undergoing chest tube insertion following iatrogenic pneumothorax following IR lung biopsy. METHODS: Retrospective chart review of patients from September 2013 to December 2017 who had chest tubes placed by IR for iatrogenic pneumothorax after CT-guided transthoracic lung biopsy at this VA center. 94 cases were identified using the IR's departmental procedure log. 78 cases had sufficient documentation for analysis. Chest tube failure was defined as expanding pneumothorax requiring additional tube or upsized chest tube insertion or tension pneumothorax requiring urgent intervention. The most common reason for exclusion was lack of documentation about the size of chest tube placed. RESULTS: Four cases involved placement of a 6.5 Fr catheter, 3 cases with an 8.5 Fr catheter, 46 cases with a 10 Fr catheter, 5 cases with a 12/12.5 Fr catheter, and 20 cases with a 14 Fr catheter. The overall failure rate in small bore chest tubes was 6.4% (5/78). The failure in small bore chest tubes less than 10 Fr was 28.5% (2/7) compared to 4.2% (3/71) in small bore chest tubes greater than or equal to 10 Fr (p = 0.06 using Fisher Exact test). Tension pneumothorax requiring ICU admission for emergent chest tube upsizing occurred in 3 patients. CONCLUSIONS: In this retrospective analysis of a VA cohort undergoing CT guided lung biopsy whose course was complicated by pneumothorax requiring chest tube, there was an overall incidence of chest tube failure in 6.4%. Though there was a trend in favor of small bore tubes greater than or equal to 10 Fr, there was no statistical difference in complications between various sizes of small bore chest tubes. A larger analysis would be needed to further explore any statistically significant difference in rate of complications between these groups. CLINICAL IMPLICATIONS: In this analysis, the overall rate of small bore chest tube failure in management of iatrogenic pneumothorax following CT-guided lung biopsy was low. Currently, neither this study nor other reviewed research provides compelling data to demonstrate benefit of any one specific size of small bore chest tube versus another. Until this is demonstrated in a more appropriately powered study, management of this condition will be subject to institutional variation. DISCLOSURES: No relevant relationships by Stephen Bujarski, source=Web Response No relevant relationships by Sunjay Devarajan, source=Web Response No relevant relationships by Sarah Tuthill, source=Web Response

Management of post-traumatic retained hemothorax

IntroductionChest injuries occur in a significant portion of trauma patients and hemothorax is a common result. While the initial management of traumatic hemothorax is most commonly treated with tube thoracostomy, the management of retained hemothorax is a subject of debate. Recent literature has proposed different methods for treating or preventing retained hemothorax, yet the approach to this pathology is not straightforward.MethodsThe literature was reviewed for relevant studies regarding the prevention and management of post-traumatic retained hemothorax. What follows is a review of the recent literature and an algorithm for the approach to treating a traumatic retained hemothorax.ResultsIdentifying a traumatic retained hemothorax and preventing subsequent complications such as pneumonia, empyema, and fibrothorax are significant issues faced by surgeons. Studies for preventing retained hemothorax have focused on initial chest tube size, location, and peri-procedural placement conditions, as well as thoracic lavage. Several treatment modalities exist, including second drainage procedure and intra-pleural fibrinolytic drug instillation, but video-assisted thoracoscopic surgery is the most common and successful approach. Regardless of the approach to evacuation, early intervention is paramount.ConclusionFurther studies will help characterize appropriate candidates, timing, treatment modalities, and guide therapy for retained hemothorax.

Conventional versus pigtail chest tube-are they similar for treatment of malignant pleural effusions?

The optimal chest tube type and size for drainage and chemical pleurodesis of malignant pleural effusions remains controversial. This retrospective study was conducted to compare the efficacy of conventional versus pigtail chest tube in the treatment of malignant pleural effusions. Patients submitted to chest tube drainage and slurry talc pleurodesis due to malignant pleural effusion in our pulmonology ward from 2012 to 2016 were eligible. According to the type of chest tube, they were divided into two groups: group I-conventional chest tube and group II-pigtail chest tube. Number of deaths, recurrence of malignant pleural effusion, and timelines associated with the procedures were reviewed and compared between groups. Out of the 61 included patients, 46 (75.4%) were included in group I and 15 (24.6%) in group II. Only one patient had pigtail chest tube obstruction, with posterior insertion of conventional chest tube. Death during hospital stay and up to 3months, recurrence at 4weeks, total duration of hospital stay, time from chest tube insertion to pleurodesis, and time from chest tube insertion to removal were not significantly different between the two groups (all p > 0.05). These findings suggest that pigtail chest tube can be an alternative on palliation, with no compromise in pleurodesis performance.

Effect of chest tube size on pleurodesis efficacy in malignant pleural effusion: a meta-analysis of randomized controlled trials.

Malignant pleural effusion (MPE) develops in approximately 50% of all patients with metastatic cancer. The efficacy of small- vs. large-bore chest tube for pleurodesis in patients with MPE is still not clear. We performed a meta-analysis to evaluate the efficacy and safety of chest tube size in the management of MPE. A systematic search of Medline (Ovid) and Embase (from 1980 to March 2016) was performed. Randomized clinical trials (RCTs) evaluating the effect of small (≤14 French) vs. large (>14 French) chest tube size on successful pleurodesis for patients with MPE. Of 708 potentially relevant publications, four matched the selection criteria and were included in the meta-analysis. Overall relative risk (RR) with 95% confidence intervals (CI) was pooled using a random-effects model. Heterogeneity was assessed using Q statistic (significant at P<0.1). In the 231 patients, the success proportion of pleurodesis as well as complication proportion were comparable between large and small chest tube groups with a pooled RR of 0.90 (95% CI, 0.77-1.05; P=0.19; I2 =17.4%) and 0.95 (95% CI, 0.42-2.15; P=0.90; I2 =0.9%) respectively. Successful pleurodesis and complication proportion for small vs. large chest tubes were 73.8% vs. 82.0% and 13.0% vs. 10.5%, respectively. This meta-analysis suggests that small and large chest tubes are both effective treatment for MPE with similar successful pleurodesis and complication proportion. Further RCTs are needed to more clearly determine which size tube is superior.

The influence of chest tube size and position in primary spontaneous pneumothorax.

Optimal chest tube position in the pleural cavity is largely unexplored for the treatment of primary spontaneous pneumothorax (PSP). We investigated whether type, size and position of chest tubes influenced duration of treatment for PSP. A retrospective follow-up study of all patients admitted with PSP over a 5-year period. Traumatic, iatrogenic and secondary pneumothoraxes were excluded. Gender, age, smoking habits, type and size of chest tube used (pigtail catheter or surgical chest tube) were recorded from the patients' charts. All chest X-rays upon admittance and immediately following chest tube placement were retrieved and re-evaluated for size of pneumothorax (categorized into five groups) and location of the chest tube tip (categorized as upper, middle or lower third of the pleural cavity). All data were analysed in a Cox proportional hazards regression model. We identified 134 patients with PSP. Baseline characteristics were similar for patients treated with surgical chest tubes and pigtail catheters. Chest tube duration was not significantly influenced by position of the chest tube tip, but was significantly longer in females (P<0.01), patients <30 years (P=0.01), larger pneumothoraxes (P<0.01), use of surgical chest tubes (P=0.03) and a history of previous pneumothorax (P=0.04). Contrary to common belief and guidelines recommendation the position of a chest tube in the pleural cavity did not significantly influence chest tube duration, but it was significantly longer in patients who were treated with a surgical chest tube.