Large-bore Chest Tubes Research Articles

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.

Institutional Guideline May Not Be Enough to Change Practice in the Management of Traumatic Hemothorax (HTX) and Pneumothorax (PTX) Management

Traumatic hemothorax and pneumothorax (HTX/PTX) are traditionally treated with large-bore chest tubes, which can lead to pain and complications. Recent studies suggest pigtail catheters can be utilized as a non-inferior alternative. The Departments of Surgery and Emergency Medicine at NewYork Presbyterian – Weill Cornell Medical Center developed an institutional guideline to standardize tube size for treating traumatic HTX/PTX, aiming to reduce the use of large-bore thoracotomy tubes without causing adverse patient outcomes. This project at NYP-WCM included patients over 18 years of age admitted with thoracic injuries resulting in HTX or PTX treated with a chest tube from January 2022 to November 2023. Patients were identified through ICD codes in the trauma registry and electronic medical record. The primary outcome was adherence to the newly developed guideline for placing thoracostomy tubes. Conversion from pigtail to larger-bore chest tube and other adverse events were secondary outcomes. We identified 18 pre-guideline and 27 post-guideline HTX/PTX patients meeting the criteria. Before the guideline implementation, 15 out of 18 patients (83%) received care consistent with the guideline (no large-bore chest). After implementation, 25 out of 27 patients (93%) received care consistent with the guideline. Based on chart review, none of the patients in the pigtail cohort experienced complications or required conversion to a larger chest tube. Although the impact was modest, implementation of the institutional guideline correlates with a reduction in “unnecessary” large-bore chest tubes for treating traumatic HTX/PTX and showed a trend toward pigtail adoption. Placement of pigtails was not linked to negative complications or treatment failure, indicating a non-inferior safety and effectiveness profile for addressing traumatic HTX/PTX.

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.

Pigtail Catheter versus Large Bore Chest Tube for the Management of Spontaneous Pneumothorax in Children: A Retrospective Study.

Pigtail catheter (PGC) insertion due to spontaneous pneumothorax (SPT) in the pediatric population has increased markedly in the last years. However, only few studies examined its efficacy in terms of length of hospitalization, rate of complications, and especially pain management comparing to large bore catheter (LBC) insertion. We sought to compare analgetic drug consumption, efficacy, and complication rate between PGC and LBC in children with SPT. This is a single-center retrospective study of pediatric patients that were admitted to the Schneider Children's Medical Center between 2013 and 2021 with a diagnosis of SPT. The following data were collected: type of drainage (PGC or LBC), duration of drainage, length of hospitalization, number of X-rays, complication rate, surgery during hospitalization, readmission due to SPT, and pain management. Seventeen PGC and 23 LBC were inserted in our study. No differences were noted in terms of hospitalization length, tube reposition or replacement, and recurrence of SPT between the groups. Patients with PGC underwent less X-rays comparing to the LBC group (3 X-rays vs. 5, median, p < 0.005). Oral analgesic use in terms of length of therapy was significantly lower in the PGC group than in the LBC group (1 vs. 3+ days, median, p < 0.05). There was no major complication in this cohort. PGC is an effective, safe, and less painful alternative compared with a LBC for the drainage of SPT in children.

Comparison of Morbidity Associated with the use of Large Versus Small-Bore Chest Tubes in Patients Managed for Stage-I Empyema Thoracis

Objective: To compare pain and other complications with the use of large versus small-bore chest tubes in patients managed for Stage-I empyema thoracis.&#x0D; Study Design: Cross-sectional study.&#x0D; Place and Duration of Study: Combined Military Hospital, Multan Pakistan, from Jan 2015 to Jan 2022.&#x0D; Methodology: The study was conducted at the Trauma and Surgery Department. Files and charts of patients who were managed for Stage-I empyema thoracic in our hospital during the study period were assessed in detail. Patients were divided into two groups based on the size of the chest tube inserted to manage empyema thoracic. The presence of post-operative pain, obstruction, dislodgment and tube site infection were compared in both groups.&#x0D; Results: Out of 90 patients of Stage-I empyema thoracic, 43(47.8%) were inserted in small-bore chest tubes, while 47(52.2%) were inserted in large-bore chest tubes. Post-procedural pain was found significantly more in patients inserted in large chest tubes than those inserted in small bore tubes (p-value-0.018). All other complications did not differ statistically significantly in both groups.&#x0D; Conclusion: Most patients in both groups did not show significant complications after the chest tube insertion. Small chest tubes were better in terms of less post-procedural pain than large chest tubes, but other complications were not significantly different in both groups.Key words: Chest tube, Empyema, Pain, Thoracis.

Reintervention Rate After Pigtail Catheter Insertion Compared to Surgical Chest Tubes.

Prior studies suggest similar efficacy between large-bore chest tube (CT) placement and small-bore pigtail catheter (PC) placement for the treatment of pleural space processes. This study examined reintervention rates of CT and PC in patients with pneumothorax, hemothorax, and pleural effusion. This retrospective study examined patients from September 2015 through December 2020. Patients were identified using ICD codes for pneumothorax, hemothorax, or pleural effusion. Use of a pigtail catheter (≤14Fr) or surgical chest tube (≥20Fr) was noted. The primary outcome was overall reintervention rate within 30days of tube insertion. Patients who died with a pleural drainage catheter in place, unrelated to complications from chest tube placement, were excluded. There were 1032 total patients in the study: 706 CT patients and 326 PC patients. The PC group was older with more comorbidities and more likely to have effusion as the indication for pleural drainage. Patients with PC were 2.35 times more likely to have the tube replaced or repositioned (P < .0001), 1.77 times more likely to require any reintervention (P = .001) and 2.09 times more likely to remain in the hospital >14days (P < .0001) compared to patients with CT. PCs have a significantly higher reintervention rate compared to CT for the treatment of pneumothorax, hemothorax, and pleural effusion. Although PC are believed to cause less pain and tissue trauma, they do not necessarily drain the pleural space as well as CT. Decisions on which method of draining the chest should be made on a case-by-case basis.

MANAGEMENT OF PNEUMOTHORAX AND PNEUMOMEDIASTINUM IN COVID-19 PATIENTS WITH ARDS

SESSION TITLE: What Lessons Will We Take From the Pandemic?SESSION TYPE: Rapid Fire Original InvPRESENTED ON: 10/19/2022 11:15 am - 12:15 pmPURPOSE: Since the emergence of COVID-19, many serious complications have arisen especially in the setting of Acute Respiratory Distress Syndrome (ARDS) in the intensive care unit. Historically, ARDS and mechanical ventilation is associated with higher rates of pneumothorax. It has been well described that ARDS is the result of inflammatory lung injury, with increased activation of circulating neutrophils, complement and proinflammatory mediators leading to loss of surfactant, alveolar atelectasis, and fibrin deposition. This leads to a less compliant lung parenchyma, and higher airway pressures, which has been attributed as a risk factor for pneumothorax. The management of pneumothorax varies depending on the etiology of the pneumothorax. In the case of iatrogenic pneumothorax (i.e. mechanical ventilation), tube thoracostomy is generally recommended, however the size of the chest tube inserted remains less clear.METHODS: This is a multi-center retrospective cohort study of 88 hospitalized patients with a diagnosis of COVID-19 and pneumothorax or pneumomediastinum between the dates of 3/11/2020 to 01/26/2021. Patient demographics, comorbidities, laboratory and hemodynamic data were collected as well as ventilator settings, lung mechanics, and clinical patient outcome data including type of intervention and rate of resolution of pneumothorax. Final statistical analysis is pending.RESULTS: Our preliminary results reveal that there was a higher rate of resolution of pneumothorax with a large bore chest tube (LBCT) compared to a small bore chest tube (SBCT). There was no significant difference in lung compliance or tidal volume in cc/kg between the patients with a resolving pneumothorax compared to the patients with a nonresolving pneumothorax. Overall mortality rate among all patients was 70.4%.CONCLUSIONS: Patients with a large bore chest tube placed are more likely to have resolution of pneumothorax compared to small bore chest tube or serial X-ray. Lung compliance and tidal volume were not significantly different between patients that had a resolving pneumothorax compared to nonresolving pneumothorax. It is important to manage a pneumothorax early on to reduce associated morbidity.CLINICAL IMPLICATIONS: The development of pneumothorax in COVID patients with ARDS has significant associated morbidity and mortality. Utilization of a large bore chest tube may result in improved rates of resolution of pneumothorax.DISCLOSURES: No relevant relationships by Nathalie AntoniosNo relevant relationships by Colby BakerNo relevant relationships by Jessica JohnsonNo relevant relationships by Karen Sayad SESSION TITLE: What Lessons Will We Take From the Pandemic? SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Since the emergence of COVID-19, many serious complications have arisen especially in the setting of Acute Respiratory Distress Syndrome (ARDS) in the intensive care unit. Historically, ARDS and mechanical ventilation is associated with higher rates of pneumothorax. It has been well described that ARDS is the result of inflammatory lung injury, with increased activation of circulating neutrophils, complement and proinflammatory mediators leading to loss of surfactant, alveolar atelectasis, and fibrin deposition. This leads to a less compliant lung parenchyma, and higher airway pressures, which has been attributed as a risk factor for pneumothorax. The management of pneumothorax varies depending on the etiology of the pneumothorax. In the case of iatrogenic pneumothorax (i.e. mechanical ventilation), tube thoracostomy is generally recommended, however the size of the chest tube inserted remains less clear. METHODS: This is a multi-center retrospective cohort study of 88 hospitalized patients with a diagnosis of COVID-19 and pneumothorax or pneumomediastinum between the dates of 3/11/2020 to 01/26/2021. Patient demographics, comorbidities, laboratory and hemodynamic data were collected as well as ventilator settings, lung mechanics, and clinical patient outcome data including type of intervention and rate of resolution of pneumothorax. Final statistical analysis is pending. RESULTS: Our preliminary results reveal that there was a higher rate of resolution of pneumothorax with a large bore chest tube (LBCT) compared to a small bore chest tube (SBCT). There was no significant difference in lung compliance or tidal volume in cc/kg between the patients with a resolving pneumothorax compared to the patients with a nonresolving pneumothorax. Overall mortality rate among all patients was 70.4%. CONCLUSIONS: Patients with a large bore chest tube placed are more likely to have resolution of pneumothorax compared to small bore chest tube or serial X-ray. Lung compliance and tidal volume were not significantly different between patients that had a resolving pneumothorax compared to nonresolving pneumothorax. It is important to manage a pneumothorax early on to reduce associated morbidity. CLINICAL IMPLICATIONS: The development of pneumothorax in COVID patients with ARDS has significant associated morbidity and mortality. Utilization of a large bore chest tube may result in improved rates of resolution of pneumothorax. DISCLOSURES: No relevant relationships by Nathalie Antonios No relevant relationships by Colby Baker No relevant relationships by Jessica Johnson No relevant relationships by Karen Sayad

It is Time to Replace Large Drains with Small Ones After Fixation of Rib Fractures: A Prospective Observational Study.

IntroductionLarge-bore chest tubes are usually applied after thoracic surgery. Recently, small-bore tubes have been increasingly considered owing to the extensive use of video-assisted thoracoscopic surgery (VATS). This study assessed the differences in outcomes between large-bore and small-caliber drainage tubes in patients undergoing surgical stabilization of rib fractures (SSRF) with VATS.MethodsOverall, 131 patients undergoing SSRF with VATS were prospectively enrolled, including 65 patients receiving 32-Fr chest tubes (group 1) and 66 patients receiving 14-Fr pigtail catheters (group 2) for postoperative drainage. The clinical characteristics and perioperative outcomes of the patients were compared.ResultsAll patients underwent SSRF with VATS within 4 days after trauma. After the operation, the mean duration of chest tubes was longer than that of pigtail catheters, with statistical significance (5.08 ± 2.47 vs 3.11 ± 1.31, P = 0.001). Length of stay (LOS) was also longer in group 1 (10.38 ± 2.90 vs 8.18 ± 2.44, P = 0.001). After multivariate logistic regression, the only independent factors between the two groups were duration of postoperative drainage (adjusted odds ratio [AOR] 1.746; 95% confidence interval [CI] 0.171–10.583, P = 0.001) and hospital LOS (AOR 1.272; 95% CI 0.109–4.888, P = 0.027).ConclusionAfter reconstruction of the chest wall and lung parenchyma, small-caliber drainage catheters could be easily and safely applied to reduce hospital LOS.

Letter to the editor: The small (14 Fr) percutaneous catheter (P-CAT) versus large (28-32 Fr) open chest tube for traumatic hemothorax: A multicenter randomized clinical trial.

In Brief Pigtail catheters may be preferable to large-bore chest tubes in stable patients with traumatic hemothorax. However, we argue the recent randomized controlled trial comparing the two has not established either the safety or efficacy of small-bore pigtail catheters in trauma.

Traumatic Pneumothorax: A Review of Current Diagnostic Practices And Evolving Management.

Pneumothorax (PTX) is defined as air in the pleural space and is classified as spontaneous or nonspontaneous (traumatic). Traumatic PTX is a common pathology identified in the emergency department. Traditional management calls for chest x-ray (CXR) diagnosis and large-bore tube thoracostomy, although recent literature supports the efficacy of lung ultrasound (US) and more conservative approaches. There is a paucity of cohesive literature on how to best manage the traumatic PTX. This review aimed to describe current practices and future directions of traumatic PTX management. Lung US has proven to be a potentially more useful tool in the detection of PTX in the trauma bay compared with CXR, and has the potential to become the new gold standard for diagnosing traumatic PTX. Computed tomography remains the ultimate gold standard, although in the setting of trauma, its utility lies more in confirming the presence and measuring the size of a PTX. The traditional mantra calling for large-bore chest tubes as first-line approaches to traumatic PTX is challenged by recent literature demonstrating pigtail catheters as equally efficacious alternatives. In patients with small or occult PTXs, even observation may be reasonable. Modern management of the traumatic PTX is shifting toward use of US for diagnosis and more conservative management practices (smaller catheters or observation). Ultimately, this shift is favorable in reducing length of stay, development of complications, and pain in the trauma patient.

SPONTANEOUS TENSION PNEUMOMEDIASTINUM: MANAGEMENT IN PNEUMOCYSTIS JIROVECI PNEUMONIA

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Spontaneous secondary pneumothorax has been reported in up to 35% of patients with Pneumocystis jirovecii (PCJ) pneumonia with human immunodeficiency virus (HIV), however, associated with bilateral pneumothorax and pneumomediastinum is a rare life-threatening condition. We present an interesting case of non-surgical management of spontaneous bilateral pneumothorax with tension pneumomediastinum in an immunocompromised individual with mediastinal drain and large-bore chest tube at the bedside with significant improvement in symptoms and hemodynamic improvement. CASE PRESENTATION: 54 years old non-compliant with his medicines with a history of HIV, type II diabetes mellitus came with complaints of dyspnea on exertion, non-productive cough for 2-3 weeks. On admission, he was afebrile, tachypneic, tachycardiac with bilateral coarse breath sounds on physical exam. Chest x-ray on admission showed bilateral multifocal opacities without any pleural effusion or pneumothorax and initial laboratory results were unremarkable. He developed spontaneous subcutaneous emphysema with crepitus extending up to his neck and face three days into hospitalization. Computed Tomography (CT) chest showed bilateral ground-glass opacities, bilateral pneumothorax, and extensive pneumomediastinum along the neck with mass effect on the heart. Initially, bilateral chest tubes were placed with improvement in pneumothoraces but persistent air leaks. One week later, he had worsening pneumomediastinum with acute hypoxic respiratory failure and obstructive shock requiring mechanical ventilation. An emergent 8 Fr mediastinal drain was placed by the ICU team at the bedside under fluoroscopy guidance with improvement in his hemodynamic status. Bronchoscopy with bronchoalveolar lavage showed PCJ DNA on PCR. His symptoms resolved over the course of hospitalization and he was discharged home on room air after a prolonged hospitalization on Biktarvy® and trimethoprim-sulfamethoxazole. DISCUSSION: PCJ pneumonia should be considered as a cause of pulmonary infection in HIV patients, subcutaneous emphysema leading to pneumothorax and pneumomediastinum has been reported with high mortality rates. Spontaneous pneumothorax develops secondary to cyst or bleb rupture due to PCJ pneumonia. Spontaneous pneumomediastinum may occur due to an abrupt increase in the trans-alveolar pressure gradient due to infections, trauma, violent coughing, or can be iatrogenic; however, tension pneumomediastinum is extremely rare. In this case, urgent treatment of pneumomediastinum at the bedside with early treatment initiation for PCP without BAL results was a life-saving measure. CONCLUSIONS: Early recognition of symptoms in immunocompromised individuals, point-of-care ultrasound, and bedside procedures in an emergent setting in non-surgical candidates in the ICU are life-saving measures with prompt anti-microbial therapy for successful treatment. REFERENCE #1: Park YK, Jung HC, Kim SY, et al. Spontaneous Pneumomediastinum, Pneumopericardium, and Pneumothorax with Respiratory Failure in a Patient with AIDS and Pneumocystis jirovecii Pneumonia. Infect Chemother. 2014;46(3):204-208. doi:10.3947/ic.2014.46.3.204 REFERENCE #2: Yee D, Fu D, Hui C, Dharmadhikari N, Carino G. A Rare Case of 4 Ps: Bilateral Pneumothoraces and Pneumomediastinum in Pneumocystis Pneumonia. R I Med J (2013). 2020 Jun 1;103(5):52-54. PMID: 32481782 REFERENCE #3: Saleem N, Parveen S, Odigwe C, Iroegbu N. Pneumomediastinum, pneumorrhachis, and subcutaneous emphysema in Pneumocystis jiroveci pneumonia in AIDS. Proc (Bayl Univ Med Cent). 2016;29(2):188-190. doi:10.1080/08998280.2016.11929412 DISCLOSURES: No relevant relationships by Mahnoor Mir, source=Web Response No relevant relationships by Jay Peters, source=Web Response No relevant relationships by Jorge Villalpando, source=Web Response

Incidence, Management, and Outcomes of Patients With COVID-19 and Pneumothorax

BackgroundOur objective was to report the incidence, management, and outcomes of patients who developed a secondary pneumothorax while admitted for coronavirus disease 2019 (COVID-19). MethodsA single-institution, retrospective review of patients admitted for COVID-19 with a diagnosis of pneumothorax between March 1, 2020, and April 30, 2020, was performed. The primary assessment was the incidence of pneumothorax. Secondarily, we analyzed clinical outcomes of patients requiring tube thoracostomy, including those requiring operative intervention. ResultsFrom March 1, 2020, to April 30, 2020, 118 of 1595 patients (7.4%) admitted for COVID-19 developed a pneumothorax. Of these, 92 (5.8%) required tube thoracostomy drainage for a median of 12 days (interquartile range 5-25 days). The majority of patients (95 of 118, 80.5%) were on mechanical ventilation at the time of pneumothorax, 17 (14.4%) were iatrogenic, and 25 patients (21.2%) demonstrated tension physiology. Placement of a large-bore chest tube (20 F or greater) was associated with fewer tube-related complications than a small-bore tube (14 F or less) (14 vs 26 events, P = .011). Six patients with pneumothorax (5.1%) required operative management for a persistent alveolar-pleural fistula. In patients with pneumothorax, median hospital stay was 36 days (interquartile range 20-63 days) and in-hospital mortality was significantly higher than for those without pneumothorax (58% vs 13%, P < .001). ConclusionsThe incidence of secondary pneumothorax in patients admitted for COVID-19 is 7.4%, most commonly occurring in patients requiring mechanical ventilation, and is associated with an in-hospital mortality rate of 58%. Placement of large-bore chest tubes is associated with fewer complications than small-bore tubes.

Routine chest X-rays after pigtail chest tube removal rarely change management in children

BackgroundThe need for chest X-rays (CXR) following large-bore chest tube removal has been questioned; however, the utility of CXRs following removal of small-bore pigtail chest tubes is unknown. We hypothesized that CXRs obtained following removal of pigtail chest tubes would not change management.MethodsPatients < 18 years old with pigtail chest tubes placed 2014–2019 at a tertiary children’s hospital were reviewed. Exclusion criteria were age < 1 month, death or transfer with a chest tube in place, or pigtail chest tube replacement by large-bore chest tube. The primary outcome was chest tube reinsertion.Results111 patients underwent 123 pigtail chest tube insertions; 12 patients had bilateral chest tubes. The median age was 5.8 years old. Indications were pneumothorax (n = 53), pleural effusion (n = 54), chylothorax (n = 6), empyema (n = 5), and hemothorax (n = 3). Post-pull CXRs were obtained in 121/123 cases (98.4%). The two children without post-pull CXRs did not require chest tube reinsertion. Two patients required chest tube reinsertion (1.6%), both for re-accumulation of their chylothorax.ConclusionsPost-pull chest X-rays are done nearly universally following pigtail chest tube removal but rarely change management. Providers should obtain post-pull imaging based on symptoms and underlying diagnosis, with higher suspicion for recurrence in children with chylothorax.

Proteus empyema as a rare complication from an infected renal cyst, a case report

BackgroundThe most commonly isolated organisms in a parapneumonic effusion include S. pneumoniae, H. influenzae, and S. aureus. If unusual organisms are isolated from the pleural space, further investigation is warranted to locate the primary source. We present a patient with an infected chronic renal cyst found to have an empyema secondary to Proteus mirabilis to highlight the importance of further diagnostic workup when encountering unusual organisms in the pleural space.Case presentationA 40-year-old African-American female, with a past medical history of asthma and sickle cell trait, presented with 5 weeks of upper respiratory tract symptoms and chest pain. A computed tomography angiogram (CTA) of the chest was negative for a pulmonary embolism but revealed a loculated left sided pleural effusion with associated left-lower lobe consolidation. She was started on empiric antibiotics, and a chest tube was inserted with drainage of frank pus. Fluid gram stain was positive for gram negative rods.Intrapleural fibrinolytics were administered for 72 h given the presence of loculations. With no improvement following fibrinolytics, she was taken to the operating room for large bore chest tube placement and left visceral pleura decortication. Pleural fluid cultures speciated to Proteus mirabilis, so further cross-sectional imaging of her abdomen/pelvis was pursued to evaluate for a primary source. A complex cystic lesion in the upper pole of the left kidney that communicated with the ipsilateral diaphragm was identified. Subsequent drainage and culture of the renal cyst was positive for Proteus mirabilis. Given clinical improvement following these interventions she was discharged with an extended course of antibiotics with plans for repeat imaging following completion of treatment.ConclusionsWhile cases of Proteus mirabilis empyema have previously been reported as a consequence of conditions such as pyelonephritis, we present, to our knowledge, the first case of a Proteus mirabilis empyema as a consequence of an infected renal cyst communicating with the pleural space. This study highlights that further evaluation with cross-sectional imaging is warranted when unusual organisms are found in the pleural space. Anatomic abnormalities that become apparent on imaging may help elucidate the source of infection.

ULTRASOUND VS NON-ULTRASOUND PIGTAIL CATHETERS INSERTION FOR PNEUMOTHORAX MANAGEMENT

SESSION TITLE: Disorders of the Pleura Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Determining the etiology of pneumothorax dictates immediate and definitive management. As such, tube thoracostomy has become the initial used modality for pneumothorax. Choosing between Ultrasound (US) or not US guided thoracostomy for pneumothorax insertion varies significant between institutions, experienced personnel, and pneumothorax type. Pigtail catheters offer a safe and effective alternative for large-bore chest tubes to patients experiencing pneumothorax. In this study, we aimed to assess the rate of complications between US and non-US Guided pigtail insertion for pneumothorax. METHODS: A retrospective analysis was performed of tube thoracostomy for treatment of pneumothorax in adult patients completed at a tertiary referral center. Data relating to intra and post-procedural complications and the need of alternative or further interventions were extracted from the institutional database. Complications were assessed using a multivariate logistic regression accounting for confounders between US and non-US guided thoracostomy. RESULTS: A total 218 pigtail catheters for treatment of pneumothorax were performed in 200 unique patients (120 patients underwent non-US-guided and 80 US-guided catheter insertion). One Hundred ten (55.0%) were placed by the Thoracic Surgery group and fifty-four (27.0%) by the Interventional Pulmonary group. A total of 18 (9.0%) patients suffered minor complications after chest tube insertion, 12 (10.0%) in the non-US group and 6 (7.5%) in the US group (p=0.724). None of the patients developed major complications. After adjusting for age, gender, and pneumothorax type there were no statistically significant association between US-Guided pigtail insertion and minor complications (OR 0.67 [CI: 0.23-1.97]). CONCLUSIONS: Our study suggests that there is no statistically significant difference between US and non-US guided small-bore catheters insertion for pneumothorax. Nevertheless, there may be a clinically significant reduction in complications with US guided pigtail catheters. CLINICAL IMPLICATIONS: There may be a clinically significant reduction in complications with US vs non US guided pigtail catheters. DISCLOSURES: 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 Mihir Parikh, source=Web Response No relevant relationships by Priya Patel, source=Web Response

Comparing complications of small-bore chest tubes to large-bore chest tubes in the setting of delayed hemothorax: a retrospective multicenter cohort study

BackgroundPrevious studies have provided initial data suggesting that small-bore (SB, ≤ 14Fr) chest tubes have the same efficacy as large-bore (LB, > 14 Fr) chest tubes for acute hemothorax (HTX), but data continue to be lacking in the setting of delayed HTX. This study compared complications of SB chest tubes to LB tubes in patients with delayed HTX.MethodsThis was a retrospective observational study across 7.5 yrs. at 6 Level 1 trauma centers. Patients were included if 1) diagnosed with a HTX or > 1 rib fracture with bloody effusion from chest tube; 2) initial chest tube placed ≥36 h of hospital admission. Patients were excluded for hemopneumothoraces. The primary endpoint was having at least one of the following chest tube complications: tube replacement, VATS, tube falling out, tube clogging, pneumonia, retained HTX, pleural empyema. Secondary outcomes included chest tube output volume and drainage rate. Dependent/independent and parametric/non-parametric analyses were used to assess primary and secondary outcomes.ResultsThere were 160 SB patients (191 tubes) and 60 LB patients (72 tubes). Both comparison groups were similar in multiple demographic, injury, clinical features. The median (IQR) tube size for each group was as follows: SB [12 Fr (12–14)] and LB [32 Fr (28–32)]. The risk of having at least one chest tube complication was similar for LB and SB chest tubes (14% vs. 18%, p = 0.42). LB tubes had significantly larger risk of VATS, while SB tubes had significantly higher risk of pneumonia. SB tubes had significantly slower least squares (LS) mean initial output drainage rate compared to LB tubes (52.2 vs. 213.4 mL/hour, p < 0.001), but a non-parametric analysis suggested no significant difference in median drainage rates between groups 39.7 [23.5–242.0] mL/hr. vs. 38.6 [27.5–53.8], p = 0.81. LB and SB groups had similar initial output volume (738.0 mL vs. 810.9, p = 0.59).ConclusionsThere was no clearly superior chest tube diameter size; both chest tube sizes demonstrated risks and benefits. Clinicians must be aware of these potential tradeoffs when deciding on the diameter of chest tube for the treatment of delayed HTXs.

Two-Year Experience of 14 French Pigtail Catheters Placed by Procedure-Focused Hospitalists.

Recent studies show small-bore chest tubes, commonly 14 French pigtail catheters (PCs), are noninferior to large-bore chest tubes for treating various conditions, and they are associated with better patient comfort. The Medical College of Wisconsin implemented a bedside procedure service (BPS) that has been trained in the placement of PCs as an adjunct to its interventional radiology department. The data regarding consults for PC placement was collected by the BPS over a 2-year period. Primary outcomes reviewed were insertion-related complications (IRCs), unsuccessful attempts (UAs), and adverse outcomes (AOs) because the authors believe these represent the safety and effectiveness of the group. It was determined which services consulted the BPS for PC placement, the indications for consults, and a brief review of declined PC consults. Of the 124 accepted consults, the service had 3 IRCs (2.4%), 2 UAs (1.6%), and 3 AOs (2.4%). A total of 18 consults were declined. The BPS was consulted by 12 services with 8 primary reasons for PC placement. At high-volume, tertiary care centers, and with the support of cardiothoracic surgical and interventional radiology services, procedure-focused hospitalists can safely serve as an adjunct service for PC placement in selected hospitalized patients.

The effectiveness of small-bore intercostal catheters versus large-bore chest tubes in the management of pleural disease with the systematic review of literature.

Objective:The purpose of this study was to compare the effectiveness of small-bore intercostal catheters (SB ICCs; 10–14 Fr) to large-bore intercostal tubes (LB ICTs; >20 Fr) in the management of pleural diseases.Methods:A total of 52 patients (42 males) with a mean age of 55 ± 23 years undergoing pleural intervention were included in the analysis. Twenty-five patients (48.1%) had pneumothorax and rest (51.9%) had pleural effusion. Half of the patients underwent SB ICC (mean age: 63 ± 20 years) and the remaining 26 underwent LB ICT (mean age: 47 ± 25 years).Results:SB ICCs were predominantly used in patients with primary pleural effusion and LB ICTs in patients presenting with pneumothorax. Failures were in <20% of SB ICC patients (mainly from loculation) and in <30% with LB ICT patients (from persistent airleak) – difference that was not statistically significant. In both groups, no deaths or major complications directly related to the procedure were observed. However, the proportion that needed surgery was significantly different in two cohorts (18.5% OF SB ICC and 42.3% of LB ICT cohorts). The ICC dwell time was less in SB ICC (5 ± 4 days), compared to LB ICT (8 ± 6 days). SB ICCs were associated with less pain and seem to be tolerated better by the patients.Conclusions:In well-supervised tertiary hospital setting, SB ICCs are as effective as LB ICTs with better patient tolerance, reduced dwell time, and reduced likelihood for surgical intervention.

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