Large-bore Tubes Research Articles

Specialised Intensive Care Treatment Concepts for Severe Chest Trauma

This review covers key elements of the critical care management of patients with thoracic trauma. Contrast-enhanced chest computertomography remains the diagnostic modality of choice, as it is more sensitive than conventional chest imaging. Regarding risk stratification, special caution is required in older patients with thoracic trauma given their high risk for posttraumatic complications. In the case of respiratory insufficiency, an attempt of non-invasive ventilation techniques is justified in most patients due to potential treatment benefits. Achieving sufficient pain control is a fundamental goal of critical care management. In this regard, erector-spinae-block and paravertebral block present potentially advantageous alternatives to thoracic epidural anaesthesia. In stable patients, the placement of small-calibre chest tubes may be a beneficial approach compared with large-bore tubes. If surgical stabilization of rib fractures is indicated, it should be done as early as possible.

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.

Protocolo diagnóstico y terapéutico de la hemoptisis

The medical record allows us to make a precise diagnosis and evaluate the severity of an episode of hemoptysis. A simultaneous evaluation and approach are essential for treatment success. The main objective is to ensure adequate ventilation, oxygenation, and intravenous access. A multidisciplinary team will be activated to stabilize and control bleeding in life-threatening hemoptysis and admission to the intensive care unit. Intubation must not be delayed if a large-bore tube is not available. A chest x-ray should be the first imaging test performed. A multidetector computed tomography (CT) scan of the chest must be performed in stable patients. A flexible bronchoscopy is the diagnostic and treatment procedure of choice in unstable patients. A rigid bronchoscopy is only used when greater blood suction capacity and visualization of the airway is needed. Emergency surgery is reserved for failed bronchoscopy and embolization interventions.

One-lung ventilation using a laryngeal mask airway and bronchial blocker in a patient with vocal cord cancer: a case report

BackgroundOne-lung ventilation is a standard technique for thoracic anesthesia. Usually, one-lung ventilation requires a large-bore tracheal tube. Therefore, in patients with vocal cord morbidity, it is challenging to achieve one-lung ventilation while preventing the damage of vocal cord lesions.Case presentationA 77-year-old man was diagnosed with vocal cord cancer and lung tumor. One-lung ventilation with a combination of a laryngeal mask airway and bronchial blocker was planned to avoid unexpected vocal cord injury. After securing the airway with a laryngeal mask airway, a bronchial blocker was placed under fiberscope guidance. The bronchial blocker passed through a position far enough from the vocal cord lesion. The bronchial blocker provided a clear view of the operative field. The patient’s perioperative course was uneventful.ConclusionsWhen one-lung ventilation is required for patients with vocal cord lesions, a combination of a laryngeal mask airway and bronchial blocker is considered a good option.

Therapy of Pyothorax in Cats via Small-Bore Thoracostomy Tube in Terms of Efficacy, Complications and Outcomes.

Simple SummaryWith this study we present our therapeutic strategy for cats with purulent fluid accumulation in the thorax. In addition to the systemic administration of antibiotics, the aim of the therapy is always the drainage of the purulent fluid from the thorax. For this purpose, we use a particular small-bore chest drain. The first aim of our study is to assess the efficacy and complication rate of our drainage. The second objective is to evaluate two treatment groups regarding their disease outcomes. We were able to show that our small-bore chest drain is similarly effective to the traditionally used large-bore drains. At the same time, we had a very low drain-associated complication rate. We detected no difference between the treatment groups and, thus, no effect on survival by early placement of bilateral drains into the thoracic cavity or lavage of the thoracic cavity with a heparinised solution. Our study supports the theory that drainage of purulent fluid from the thoracic cavity in cats can be performed with small-bore drains with good results and minimal risk of complications.First-line therapy for cats with pyothorax consists of intravenous antibiotics, drainage of the septic pleural effusion and closed-chest lavage. Large-bore thoracostomy tubes are traditionally used for drainage, but case series indicate a comparable efficacy using small-bore tubes. In this retrospective study, we describe a new technique of sheath-guided small-bore (6 F) thoracostomy tubes in cats with pyothorax and evaluate their efficacy and complications. Additionally, we compare outcomes between two treatment groups. Placement and use of the small-bore thoracostomy tubes described here has a low complication rate of 4% (3/67 tubes), and 53% (24/45) of the cats could be treated with thoracostomy tubes and closed-chest lavage according to the protocol. The success rate is reduced by 18% (8/45) due to deaths caused mainly by sepsis, 16% (7/45) due to structural diseases requiring surgery and a further 14% (6/43) due to lavage failures that could only be cured after additive therapy (thoracotomy or fibrinolysis). The long-term prognosis was very good, with a survival rate one year after discharge of 94% (30/32). We detected no effect on survival by early placement of bilateral thoracostomy tubes or closed-chest lavage with a heparinised solution. In conclusion, therapy of pyothorax with small-bore thoracostomy tubes is as successful as therapy with large- or medium-bore tubes.

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.

A Comparative Study Between-Small Bore and Large Bore Tubes for Therapeutic Pleural Drainage

Introduction: Pleural effusions due to various pulmonary and extra pulmonary causes are common clinical problems. Some pleural diseases require therapeutic pleurocentesis to decompress the pleural space like in malignant and benign pleural effusions, pyothorax, chylothorax, pneumothorax, complicated parapneumonic effusion and haemothoraces. Traditionally large bore tubes have been used with trocar or through blunt dissection. Nowadays small-bore catheters are gaining popularity, as they are less painful and believed to be equally efficacious as compared to large bore tubes.
 Aims & Objectives: To compare the success rate of small bore tubes with standard large bore chest tubes in therapeutic pleural drainage and to compare complications rate between small bore and large bore drains.
 Place and duration of study: The study was conducted at Department of Pulmonology of FPGMI, Shaikh Zayed Hospital, during one year (2015-2016).
 Material & Methods: Total 152 patients who required therapeutic evacuation of pleural space suffering from pneumothorax, empyema, parapneumonic and malignant effusion, were enrolled and underwent therapeutic drainage with small bore (< 20 F size) and large bore tubes (> 20 F size), randomized by lottery method.
 Results: The mean duration of drain placement for large bore drain was 7.9±3.8 days, which was significantly higher than small bore drains with a mean value of 3.0±1.6 days (p-value <0.001). The pain score was also quite high in large bore group with mean value 5.67±1.68 as compared to small bore 1.07±0.81(p-value<0.001). Similarly the mean bleeding during the procedure was significantly higher in large bore group as compared to small bore with mean values 11.9±7.8 and 0.1±0.2 ml respectively (p-value<0.001). The wound infection which is a significant complication was found only in large bore group with 14.5% cases as compared to none in small bore group (p-value 0.001). In large bore group surgery was required for 9(11.8%) cases while in small group there were 2(2.6%) patients referred for surgical intervention.
 Conclusion: Small bore thoracostomy drains are more effective than large bore tubes, for the treatment of pleural disorders requiring therapeutic drainage and they are associated with minimal pain and other complications.

Percutaneous Endoscopic Gastrostomy Large-Bore Tube Application without the Use of Endoscope: Single-Center Experience on 86 Neurologically Compromised Patients

Context: Percutaneous placement of gastrostomy tube has replaced surgical placement as the most accepted method of gastrostomy tube insertion. It can be done by an alternative nonendoscopic fluoroscopy-guided technique that combines the advantages of fluoroscopic guidance and the pull technique. Aims: This study aimed to describe a percutaneous fluoroscopy-guided technique for applying mushroom-retained large-bore gastrostomy advanced through the nose without endoscopy. Settings and Design: This retrospective study was conducted at the Interventional Radiology Unit, Ain Shams University Hospitals, Cairo, Egypt. Subjects and Methods: Between January 2015 and November 2017, 86 neurologically compromised patients underwent placement of 24F mushroom gastrostomy tubes. There were 55 males and 31 females, with the mean age of 61 years (58–87 years). Technical success and procedural complications were assessed. Follow-up data were collected retrospectively by reviewing the medical records at the neurology clinic to evaluate tube function and monitor complications. Results: Technical success rate was 100%. Procedure time varied between 10 and 13 min. No major procedure-related complications occurred. Twenty-two patients (25.5%) died during the study period with no procedure-related deaths. Nearly 34.8% of the patients (30/86 patients) could not be followed up due to loss of contact. Follow-up time ranged between 200 and 230 days in the remaining 34 patients with no evidence of tube dysfunction. Conclusions: Fluoroscopy-guided percutaneous placement of large-bore pull gastrostomy tubes inserted via nasal route showed a high rate of technical success and long-term patency with low risk of complications.

Intraoperative and postoperative feasibility and safety of total tubeless, tubeless, small-bore tube, and standard percutaneous nephrolithotomy: a systematic review and network meta-analysis of 16 randomized controlled trials

BackgroundPercutaneous nephrolithotomy (PCNL) is performed to treat relatively large renal stones. Recent publications indicate that tubeless and total tubeless (stentless) PCNL is safe in selected patients. We performed a systematic review and network meta-analysis to evaluate the feasibility and safety of different PCNL procedures, including total tubeless, tubeless with stent, small-bore tube, and large-bore tube PCNLs.MethodsPubMed, Cochrane Central Register of Controlled Trials, and EMBASE™ databases were searched to identify randomized controlled trials published before December 30, 2013. One researcher examined all titles and abstracts found by the searches. Two investigators independently evaluated the full-text articles to determine whether those met the inclusion criteria. Qualities of included studies were rated with Cochrane’s risk-of-bias assessment tool.ResultsSixteen studies were included in the final syntheses including pairwise and network meta-analyses. Operation time, pain scores, and transfusion rates were not significantly different between PCNL procedures. Network meta-analyses demonstrated that for hemoglobin changes, total tubeless PCNL may be superior to standard PCNL (mean difference [MD] 0.65, 95% CI 0.14–1.13) and tubeless PCNLs with stent (MD -1.14, 95% CI -1.65–-0.62), and small-bore PCNL may be superior to tubeless PCNL with stent (MD 1.30, 95% CI 0.27–2.26). Network meta-analyses also showed that for length of hospital stay, total tubeless (MD 1.33, 95% CI 0.23–2.43) and tubeless PCNLs with stent (MD 0.99, 95% CI 0.19–1.79) may be superior to standard PCNL. In rank probability tests, small-bore tube and total tubeless PCNLs were superior for operation time, pain scores, and hemoglobin changes.ConclusionsFor hemoglobin changes, total tubeless and small-bore PCNLs may be superior to other methods. For hospital stay, total tubeless and tubeless PCNLs with stent may be superior to other procedures.

Role of medical thoracoscopy in the treatment of tuberculous pleural effusion.

Fibrous tuberculous pleural effusion (TPE) represents common disease in tuberculous clinic. Medical thoracoscopy has been used to treat pleural empyema and shown promising outcomes, but data of its use in multiloculated and organized TPE remains limited to know. The study was performed on 430 cases with TPE. The cases were divided into free-flowing, multiloculated effusion and organized effusion group. Each group was subdivided into two or three types of therapeutic approaches: ultrasound guided pigtail catheter, large-bore tube chest drainage and medical thoracoscopy. Patients with multiloculated or organized effusions received streptokinase, introduced into the pleural cavity via chest tubes. The successful effectiveness of the study was defined as duration of chest drainage, time from treatment to discharge days and no further managements. Patients with organized effusion were older than those with free-flowing effusion and incidence of organized effusion combined with pulmonary tuberculosis (PTB) was higher than those of multiloculated effusion and free-flowing effusion respectively. Positive tuberculosis of pleural fluid culture was higher in organized effusion than that in free-flowing effusion. Sputum positive for acid-fast bacillus (AFB) in organized effusion was higher than that in multiloculated effusion and free-flowing effusion. Medical thoracoscopy showed significant efficacy in the group of multiloculated effusion and organized effusion but free-flowing effusion. No chronic morbidity and mortality related to complications was observed. Medical thoracoscopy was a safe and successful method in treating multiloculated and organized TPE.

The Pigtail Catheter for Pleural Drainage: A Less Invasive Alternative to Tube Thoracostomy

Background: Thoracostomy tubes are a mainstay of treatment for removing fluid or air from the pleural space. Placement of a chest tube is, however, an invasive procedure with potential morbidity. In an effort to reduce these complications, the use of percutaneous pigtail catheters in place of traditional large-bore tubes for thoracostomy and pleural drainage has been described. The aim of the study was to determine the role of pigtail catheters in adult population for drainage of pleural effusion. Methods: It was an observational study. All consecutive patients with pleural effusion requiring drainage were subjected to either tube thoracostomy or pig tail drainage. A standardized questionnaire was prepared for retrieving data. Outcomes of interest were time to drain and total duration of hospital stay. Results: A total of 92 patients (71 men and 21 women; age range, 17 - 86 years; mean age, 54 ± 15 years) were enrolled into the study. Thirty-five patients were treated with traditional chest tubes, whereas 57 patients were treated with pigtail catheters. There were no significant differences in either drainage days or hospitalization days between the chest tube group and pigtail catheter group (9.81 ± 6 vs. 9 ± 5.6 and 13.8 ± 6 vs. 13 ± 5.7, respectively). Conclusions: The pigtail catheter offers reliable treatment of effusions and is a safe and less invasive alternative to tube thoracostomy. There was no significant difference in time to drain and duration of hospital stay in both the groups. J Curr Surg. 2016;6(2):52-56 doi: http://dx.doi.org/10.14740/jcs300e

Endoscopic Extraction of an Anchored Chest/Mediastinal Tube

Cardiac wound bed drainage is achieved via large-bore plastic tube(s), which are typically removed within 48 hours, to lower risk of arrhythmia and tissue damage. While standard tube removal is simple and rapid, tubes inadvertently sutured to the chest wall are removed through a complex surgical procedure. Herein, we describe a novel tube extraction procedure, using an endoscopic scissor under bronchoscopic guidance. Tube extraction was achieved in all three presented cases, and patient recovery and wound healing periods were similar to those standard removal of nonsutured tubes. This report demonstrates the safety and convenience of the proposed method as a feasible alternative to invasive chest tube extraction.

Simultaneous bilateral tubeless percutaneous nephrolithotomy: A report of 2 cases and review of the literature.

Percutaneous nephrolithotomy (PCNL) is currently the standard of care to remove large renal calculi. Traditionally, a large-bore nephrostomy tube is placed postoperatively. However, the necessity of this practice has been recently challenged. Theoretically, bilateral tubeless PCNL offers advantages of lower postoperative discomfort, shorter hospital stay and thus lower cost. We review the literature and present two cases of simultaneous bilateral tubeless PCNL from two patients who were referred to a tertiary stone centre from remote areas.

Percutaneous Pancreatic Necrosectomy

A significant percentage of patients with necrotizing pancreatitis will develop an infected pancreatic necrosis that contributes to the morbidity and mortality. Infected pancreatic necrosis requires drainage and debridement. This can be performed percutaneously or surgically. Surgical management may be performed with open or minimally invasive techniques. There has been a trend toward minimally invasive surgical management in recent years. Minimally invasive management requires effective drainage through the use of large-bore drain catheters. We describe a technique that facilitates the insertion of large-bore drainage tubes within the pancreatic collections.

Re: Totally tubeless percutaneous nephrolithotomy: a prospective randomized controlled study

The study is unique in terms of defining the safety of totally tubeless percutaneous nephrolithotomy (PNL). Furthermore, the authors state that the tubeless group has an advantage of less pain. However, we interpreted the results of pain-related comparisons different than that the authors had. In our opinion, the results gained show that there is no difference in terms of pain in both groups. The authors state that they have inserted a double J catheter to patients that were included in the tubeless group in addition to the nephrostomy as a conventional procedure. However, routine Double-J placement in addition to nephrostomy is not a common procedure. Additionally, the large-bore nephrostomy tube preferred is certain to cause pain, as stated in the previous studies. It has been shown that small-bore tubes cause less pain. It may have been more appropriate to compare the groups in such a manner. Even though we have stated our comments with respect to pain issues, it is evident that the study is unique in terms of defining the safety of a totally tubeless procedure.

Optimal Chest Drain Size: The Rise of the Small-Bore Pleural Catheter

Drainage of the pleural space is not a modern concept, but the optimal size of chest drains to use remains debated. Conventional teaching advocates blunt dissection and large-bore tubes; but in recent years, small-bore catheters have gained popularity. In the absence of high-quality randomized data, this review summarizes the available literature on the choice of chest drains. The objective data supporting the use of large-bore tubes is scarce in most pleural diseases. Increasing evidence shows that small-bore catheters induce less pain and are of comparable efficacy to large-bore tubes, including in the management of pleural infection, malignant effusion, and pneumothoraces. The onus now is on those who favor large tubes to produce clinical data to justify the more invasive approach.

Chest Tube Selection in Cardiac and Thoracic Surgery: A Survey of Chest Tube-Related Complications and Their Management

Blood accumulating inside chest cavities can lead to serious complications if it is not drained properly. Because life-threatening conditions can result from chest tube occlusion after thoracic surgery, large-bore tubes are generally employed to optimize patency. The aim of this study was to better define problems with current paradigms for chest drainage. A survey was conducted of North American cardiothoracic surgeons and specialty cardiac surgery nurses. A total of 108 surgeons and 108 nurses responded. The survey revealed that clogging leading to chest-tube dysfunction is a major concern when choosing tube size. Of surgeons responding, 106 of 106 (100%) had observed chest tube clogging, and 93 of 106 (87%) reported adverse patient outcomes from a clogged tube. Despite techniques such as tube stripping, tapping, and squeezing, up to 51% of surveyed surgeons stated they are not satisfied with currently available tubes and procedures to avoid tube occlusion and some even forbid the stripping maneuver for fear of causing more bleeding by the negative pressures generated. In addition, respondents noted that patients experience increasing discomfort with increasing drain size. The major reason surgeons choose large-diameter chest tubes is linked to concern about the suboptimal available methods to avoid and treat chest-tube clogging. Even though larger tubes are thought to be associated with more pain, physicians generally err on the side of caution to avoid clogging and insert tubes with larger diameters. Results of this survey highlight the frequent problems with clogging with current postsurgical chest drainage systems and suggest the need for innovative solutions to avoid clogging complications and overcome clinician concern and patient pain.

Feeding Tube Placement in Adults: Safe Verification Method For Blindly Inserted Tubes

E nteral feeding is a common and necessary practice in critical care. Clinical practice for verification of smalland large-bore feeding tubes is variable. Although radiographic confirmation is the reference standard for blindly inserted small-bore tubes, it is not consistently performed to verify large-bore tubes before administration of formula or medication. These practices raise concerns; both smalland large-bore tube placement in the tracheobronchial tree have been reported. Malpositioning has also involved the intracranial cavity. In a review of more than 2000 insertions of small-bore tubes, 50 pulmonary placements (3%) were detected. In another study, the incidence of inadvertent pulmonary placement did not differ between smalland large-bore tubes. Of note, endotracheal or tracheostomy tube cuffs do not prevent pulmonary malposition. Unfortunately, pulmonary malplacement may occur silently, without coughing, dyspnea, or oxygen desaturation. Adding confusion, aspirated fluids that resemble gastric fluids have been obtained from tubes placed in the lungs. Malpositioned tubes may cause pneumonia, pneumothorax, perforations, empyema, and bronchopleural fistula—events that can lead to death in rare cases. The Joint Commission identified pulmonary malposition of nasogastric tubes as one of the most frequent procedural complications that result in postoperative sentinel events. Expert recommendation included checking tube placement with an abdominal radiograph. Also, failure to report malpositioned tubes and complications due to insertion continues to be a problem. In addition to pulmonary malposition, aspiration risk is high when tubes are placed in the esophagus A regular feature of the American Journal of Critical Care, Clinical Evidence Review unveils available scientific evidence to answer questions faced in contemporary clinical practice. It is intended to support, refute, or shed light on health care practices where little evidence exists. To send an eLetter or to contribute to an online discussion about this article, visit www.ajcconline.org and click “Respond to This Article” on either the full-text or PDF view of the article. We welcome letters regarding this feature and encourage the submission of questions for future review.

Gastric Residual Volume and Aspiration in Critically Ill Patients Receiving Gastric Feedings

The helpfulness of bedside assessment of gastric residual volume in the prediction of aspiration has been questioned, as has the volume that signals increased risk of aspiration. To describe the association between gastric residual volumes and aspiration of gastric contents. In a prospective study of 206 critically ill patients receiving gastric tube feedings for 3 consecutive days, gastric residual volumes were measured with 60-mL syringes every 4 hours. Measured volumes were categorized into 3 overlapping groups: at least 150 mL, at least 200 mL, and at least 250 mL. Patients were categorized as frequent aspirators if 40% or more of their tracheal secretions were positive for pepsin and as infrequent aspirators if less than 40% of their secretions were positive for pepsin. Gastric residual volumes were compared between the 2 aspiration groups. Approximately 39% of the 206 patients had 1 or more gastric residual volumes of at least 150 mL, 27% had 1 or more volumes of at least 200 mL, and 17% had 1 or more volumes of at least 250 mL. Large-bore tubes identified most of the high volumes. Eighty-nine patients were frequent aspirators. Volumes less than 150 mL were common in both aspiration groups. However, the frequent aspirators had a significantly greater frequency of 2 or more volumes of at least 200 mL and 1 or more volumes of at least 250 mL. No consistent relationship was found between aspiration and gastric residual volumes. Although aspiration occurs without high gastric residual volumes, it occurs significantly more often when volumes are high.

Modified central venous catheter for pneumothorax

Pneumothorax frequently requires drainage, and many thoracic surgeons continue to use the traditional rigid chest tubes. Traditional tube thoracostomy using a large-bore tube is an essential technique for thoracic surgeons, but it is associated with significant pain at the time of insertion and during continued drainage. We have found a new small-bore, flexible thoracostomy method using a modified central venous catheter that is simple, less painful, and safe.