Pigtail catheter for the management of pneumothorax in mechanically ventilated patients. Am J Emerg Med. 2010;28:466-471. [PMID: 20466227 DOI: 10.1016/j.ajem.2009.01.033]

Perioperative outcomes of bi-pigtail catheter drainage strategy versus conventional chest tube after uniportal video-assisted thoracic lung surgery

OBJECTIVES

Chest tube (CT) drainage is a main cause of postoperative pain in lung surgery. Here, we introduced a novel drainage strategy with bi-pigtail catheters (PCs) and conducted a randomized controlled trial to compare with conventional CT drainage after uniportal video-assisted thoracic surgery lung surgery.

METHODS

A single-centre, prospective, open-labelled, randomized controlled trial (ChiCTR2000035337) was conducted with a preplanned sample size of 396. The primary outcome was the numerical pain rating scale (NPRS) on the first postoperative day. Secondary outcomes included other indicators of postoperative pain, drainage volume, duration of drainage, postoperative hospital stay, incidence of postoperative complications, CT reinsertion and medical costs.

RESULTS

A total number of 396 patients were randomized between August 2020 and January 2021, 387 of whom were included in the final analysis. The baseline and clinical characteristics of the patients were well balanced between 2 groups. The NPRS on the first postoperative day was significantly lower in the PC group than in the CT group (2.40 ± 1.27 vs 3.02 ± 1.39, p < 0.001), as well as the second/third-day NPRS, the incidence of sudden severe pain (9/192, 4.7% vs 34/195, 17.4%, P < 0.001) and pain requiring intervention (19/192, 9.9% vs 46/195, 23.6%, P < 0.001). In addition, the medical cost in the PC group was lower (US$7809 ± 1646 vs US$8205 ± 1815, P = 0.025). Univariable and multivariable analyses revealed that the drainage strategy was the only factor influencing the incidence of pain requiring intervention.

CONCLUSIONS

The drainage strategy with bi-PCs in patients undergoing uniportal video-assisted thoracic surgery lung surgery alleviates postoperative pain with adequate safety and efficacy.

Management of pneumothorax with 8.3-French Pigtail Catheter: description of the ultrasound-guided technique and case series

Spontaneous and traumatic pneumothorax are most often treated with chest tube (CT) thoracostomy. However, it appears that small-bore drainage systems have similar success rates with lower complications, pain, and discomfort for the patient. We present the description of the ultrasound-guided technique for pneumothorax drainage with an 8.3-French pigtail catheter (PC) in a case series of 10 patients.

Incidence and management of pneumothorax, pneumomediastinum, and subcutaneous emphysema in COVID-19

Objective

The coronavirus disease 2019 (COVID-19) pandemic reached New York City in March 2020, leading to a state of emergency that affected many lives. Patients who contracted the disease presented with different phenotypes. Multiple reports have described the findings of computed tomography scans of these patients, several with pneumothoraces, pneumomediastinum, and subcutaneous emphysema. Our aim was to describe the incidence and management of pneumothorax, pneumomediastinum, and subcutaneous emphysema related to COVID-19 found on radiologic imaging.

Methods

A retrospective chart review was conducted of all confirmed COVID-19 patients admitted between early March and mid-May to two hospitals in New York City. Patient demographics, radiological imaging, and clinical courses were documented.

Results

Between early March and mid-May, a total of 1866 patients were diagnosed with COVID-19 in the two hospitals included in the study, of which 386 were intubated. The majority of these patients were men (1090, 58.4%). The distribution of comorbidities included the following: hypertension (1006, 53.9%), diabetes (544, 29.6%), and underlying lung disease (376, 20.6%). Among the 386 intubated patients, 65 developed study-specific complications, for an overall incidence of 16.8%; 36 developed a pneumothorax, 2 developed pneumomediastinum, 1 had subcutaneous emphysema, and 26 had a combination of both. The mean time of invasive ventilation was 14 days (0-46, interquartile range = 6-19, median 11). The average of highest positive end expiratory pressure within 72 h of study complication was 11 (5-24) cmH20. The average of the highest peak inspiratory pressure within 72 h of complication was 35.3 (17-52) cmH2O. In non-Intubated patients, 9/1480 had spontaneous pneumothorax, for an overall incidence of 0.61 %.

Conclusion

Intubated patients with COVID-19 pneumonia are at high risk of pneumothorax, pneumomediastinum, and subcutaneous emphysema. These should be considered in differential diagnosis of shortness of breath or hypoxia in a patient with a new diagnosis of COVID-19 or worsening hemodynamics or respiratory failure in an intensive care unit setting.

Pulmonary Barotrauma in COVID-19 Patients: Experience From a Secondary Care Hospital in Oman

Background

During the COVID-19 pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), many patients developed pulmonary barotrauma either self-inflicted or ventilator-induced. In pulmonary barotrauma, air leaks into extra-alveolar tissue resulting in pneumomediastinum, subcutaneous emphysema, pneumothorax, and pneumoperitoneum.

Methods

After obtaining institutional approval, we retrospectively reviewed data from March 1, 2021, to September 31, 2021. Being a retrospective study, informed consent was not applicable. Patient data were collected from the Al Shifa patient information portal, which is an electronic medical record system available to all hospitals in the Ministry of Health, Oman. After identifying patients with pulmonary barotrauma, the following details were recorded and entered into an Excel sheet (Microsoft Corporation, Albuquerque, New Mexico) and a database was created, which contained the following: age, sex, smoking history, comorbidities, type, location, mode of barotrauma, mode of ventilation, length of intensive care unit (ICU) stay, interventions performed, and overall outcome (survived/deceased).

Results

A total of 529 patients with COVID-19 pneumonia were admitted from March 2021 to September 2021 to the ICU. Twenty-eight patients developed barotrauma of variable severity and required interventions like the placement of intercostal drains. Out of 28, five patients developed spontaneous barotrauma, 14 patients had barotrauma after initiation of non-invasive ventilation, and nine patients had barotrauma as a result of invasive ventilation. The median number of days in the ICU was 19.5 (interquartile range: 12.5-26.5). Of the 28 patients, eight patients survived and were discharged from the hospital.

Conclusion

In this single-center, retrospective study at a secondary care hospital in Oman, we described our experience with patients who suffered pulmonary barotrauma during their ICU admission. We have also presented the incidence of spontaneous versus ventilator-induced barotrauma, the length of stay of these patients, the outcomes in terms of survival or death, the need for tracheostomy, secondary infections, and interventions performed as indicated.

Invasive mechanical ventilation complications in COVID-19 patients

Background

Since late 2019, COVID-19 infection has quickly spread substantially in all countries, forcing the appropriation of noteworthy lockdown and social separating measures. It has been considered as a pandemic by the World Health Organization. Positive pressure ventilation is a non-physiological and invasive intervention that can be lifesaving in COVID-19 patients. Similar to any other interventions, it can cause its own danger and complications as it can prompt ventilator-induced lung injury and barotrauma. The aim of the work was to identify the incidence of invasive mechanical ventilation complication in COVID-19 pneumonias, and to describe patient characteristics and patterns of barotrauma in COVID-19 patients.

Results

This retrospective study included 103 patients with COVID-19 pneumonia, 76 males and 27 females are on invasive mechanical ventilation. Their mean age was 56.6, ranged from 21 to 85 years old. Barotraumas event type in the studied patients, (NB: one or multiple barotrauma events occurring on the same day were considered as single event (95/103 patients-92.23%), while separate multiple events (8/103 patients-7.77%) were recorded when occurring separated by at least 24 h). Single barotrauma events were subdivided into: one event (67/95 patients—70.53%), & multiple events (28/95 patients—29.47%). The mean interval between invasive mechanical ventilation and developing barotraumas was 3–7 days included 41 patients (39.98%). We revealed a strong prevalence of COVID-19 IMV complication with worsening prognosis and subsequent higher death rates in elderly smoker or obese males, as well as those suffering from ARDS. Past medical history (hypertension, DM, chronic renal or cardiac disease) or surgical history of CABG was more liable for these types of complications.

Conclusion

Patients with COVID-19 pneumonia were more liable to the higher incidence of barotraumas with presence of predisposition and high risk factors. In general, an outstanding bad prognostic outcome and a significantly high mortality rate prevailed in COVID-19 patients associated with mechanically ventilated patients.

Management of Pneumothorax

Pneumothorax is a common medical condition encountered in a wide variety of clinical presentations, ranging from asymptomatic to life threatening. When symptomatic, it is important to remove air from the pleural space and provide re-expansion of the lung. Additionally, patients who experience a spontaneous pneumothorax are at high risk for recurrence, so treatment goals also include recurrence prevention. Several recent studies have evaluated less invasive management strategies for pneumothorax, including conservative or outpatient management. Future studies may help to identify who is greatest at risk for recurrence and direct earlier definitive management strategies, including thoracoscopic surgery, to those patients.

Management of complex pleural disease in the critically ill patient

Disorders of the pleural space are quite common in the critically ill patient. They are generally associated with the underlying illness. It is sometimes difficult to assess for pleural space disorders in the ICU given the instability of some patients. Although the portable chest X-ray remains the primary modality of diagnosis for pleural disorders in the ICU. It can be nonspecific and may miss subtle findings. Ultrasound has become a useful tool to the bedside clinician to aid in diagnosis and management of pleural disease. The majority of pleural space disorders resolve as the patient’s illness improves. There remain a few pleural processes that need specific therapies. While uncomplicated parapneumonic effusions do not have their own treatments. Those that progress to become a complex infected pleural space can have its individual complexity in therapy. Chest tube drainage remains the cornerstone in therapy. The use of intrapleural fibrinolytics has decreased the need for surgical referral. A large hemothorax or pneumothorax in patients admitted to the ICU represent medical emergencies and require emergent action. In this review we focus on the management of commonly encountered complex pleural space disorders in critically ill patients such as complicated pleural space infections, hemothoraces and pneumothoraces.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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 pigtail catheters relieve pneumothorax?: A PRISMA-compliant systematic review and meta-analysis

BACKGROUND

Pigtail catheter drainage has been usually applied for the treatment of pleural effusion and pneumothorax. Our aim was to investigate the application and efficacy of pigtail catheters for pneumothorax.

METHODS

We carried out a meta-analysis of retro- or pro-spective studies addressing the effect of pigtail catheters for pneumothorax. We presented success rates of pigtail catheter drainage as primary outcomes, and considered the duration of drainage, and complication rates as secondary outcomes. Pooled data were available using the fixed or random effects model. Heterogeneity, sensitivity, and subgroup analyses were performed.

RESULTS

The meta-analysis was based on 16 articles with a total of 1067 patients. Our analyses showed that pooled success rates were 0.77 (0.71-0.82), )furthermore, duration of drainage was 5.61 (3.99-7.23), and complication rates 0.18 (0.09-0.27). Subgroup results according to causes of pneumothorax and patient characteristics were robust and all consistent with overall outcomes.

CONCLUSION

These suggested that pigtail catheter insertion within radiological guidance may provide a safe and effective way for the treatment of pneumothorax. More large-scale and prospective studies were required to determine these findings.

A Systematic Review and Meta-Analysis Comparing Pigtail Catheter and Chest Tube as the Initial Treatment for Pneumothorax

BACKGROUND

The optimal initial treatment approach for pneumothorax remains controversial. This systemic review and meta-analysis investigated the effectiveness of small-bore pigtail catheter (PC) drainage compared with that of large-bore chest tube (LBCT) drainage as the initial treatment approach for all subtypes of pneumothorax.

METHODS

PubMed and Embase were systematically searched for observational studies and randomized controlled trials published up to October 9, 2017, that compared PC and LBCT as the initial treatment for pneumothorax. The investigative outcomes included success rates, recurrence rates, complication rates, drainage duration, and hospital stay.

RESULTS

Of the 11 included studies (875 patients), the success rate was similar in the PC (79.84%) and LBCT (82.87%) groups, with a risk ratio of 0.99 (95% CI, 0.93 to 1.05; I² = 0%). Specifically, PC drainage was associated with a significantly lower complication rate following spontaneous pneumothorax than LBCT drainage (Peto odds ratio: 0.49 [95% CI, 0.28 to 0.85]; I² = 29%). In the spontaneous subgroup, PC drainage was associated with a significantly shorter drainage duration (mean difference, -1.51 [95% CI, -2.93 to -0.09]) and hospital stay (mean difference: -2.54 [95% CI, -3.16 to -1.92]; P < .001) than the LBCT group.

CONCLUSIONS

Collectively, results of the meta-analysis suggest PC drainage may be considered as the initial treatment option for patients with primary or secondary spontaneous pneumothorax. Ideally, randomized controlled trials are needed to compare PC vs LBCT among different subgroups of patients with pneumothorax, which may ultimately improve clinical care and management for these patients.

TRIAL REGISTRY

PROSPERO; No.: CRD42017078481; URL: https://www.crd.york.ac.uk/prospero/.

Percutaneous pigtail catheter in the treatment of pneumothorax in major burns: the best alternative? Case report and review of literature

Multiple factors place burn patients at a high risk of pneumothorax development. Currently, no specific recommendations for the management of pneumothorax in large total body surface area (TBSA) burn patients exist. We present a case of a major burn patient who developed pneumothorax after central line insertion. After the traditional large bore (24 Fr) chest tube failed to resolve the pneumothorax, the pneumothorax was ultimately managed by a percutaneous placed pigtail catheter thoracostomy placement and resulted in its complete resolution. We will review the current recommendations of pneumothorax treatment and will highlight on the use of pigtail catheters in pneumothorax management in burn patients.

The role of interventional therapy for pleural diseases

Pleural diseases encompass a vast and heterogeneous group of diseases that have traditionally received relatively little attention from researchers, resulting in empiric approaches to patient management based largely on expert opinions and anecdotal evidence. Yet, paradoxically, pleural diseases represent a considerable burden for patients, providers, and the healthcare system as a whole, with a rising incidence of malignant pleural effusions and pleural space infections, in increasingly complex patients. Fortunately, the last decade has witnessed unprecedented research efforts from the pleural community, which have resulted in substantial advances in risk-stratification, patient selection, treatment efficacy and the development of evidence-based recommendations ultimately leading to improved patient care. In this review, we will present a summary of the current evidence for the management of pleural diseases with an emphasis on interventional procedures, and highlight the need for future research efforts in the field of malignant pleural effusions, pleural space infections and pneumothorax.

Randomized clinical trial of pigtail catheter versus chest tube in injured patients with uncomplicated traumatic pneumothorax

BACKGROUND

Small pigtail catheters appear to work as well as the traditional large-bore chest tubes in patients with traumatic pneumothorax, but it is not known whether the smaller pigtail catheters are associated with less tube-site pain. This study was conducted to compare tube-site pain following pigtail catheter or chest tube insertion in patients with uncomplicated traumatic pneumothorax.

METHODS

This prospective randomized trial compared 14-Fr pigtail catheters and 28-Fr chest tubes in patients with traumatic pneumothorax presenting to a level I trauma centre from July 2010 to February 2012. Patients who required emergency tube placement, those who refused and those who could not respond to pain assessment were excluded. Primary outcomes were tube-site pain, as assessed by a numerical rating scale, and total pain medication use. Secondary outcomes included the success rate of pneumothorax resolution and insertion-related complications.

RESULTS

Forty patients were enrolled. Baseline characteristics of 20 patients in the pigtail catheter group were similar to those of 20 patients in the chest tube group. No patient had a flail chest or haemothorax. Pain scores related to chest wall trauma were similar in the two groups. Patients with a pigtail catheter had significantly lower mean(s.d.) tube-site pain scores than those with a chest tube, at baseline after tube insertion (3.2(0.6) versus 7.7(0.6); P < 0.001), on day 1 (1.9(0.5) versus 6.2(0.7); P < 0.001) and day 2 (2.1(1.1) versus 5.5(1.0); P = 0.040). The decreased use of pain medication associated with pigtail catheter was not significantly different. The duration of tube insertion, success rate and insertion-related complications were all similar in the two groups.

CONCLUSION

For patients with a simple, uncomplicated traumatic pneumothorax, use of a 14-Fr pigtail catheter is associated with reduced pain at the site of insertion, with no other clinically important differences noted compared with chest tubes.

REGISTRATION NUMBER

NCT01537289 (http://clinicaltrials.gov).

Iatrogenic pneumothorax related to mechanical ventilation

Pneumothorax is a potentially lethal complication associated with mechanical ventilation. Most of the patients with pneumothorax from mechanical ventilation have underlying lung diseases; pneumothorax is rare in intubated patients with normal lungs. Tension pneumothorax is more common in ventilated patients with prompt recognition and treatment of pneumothorax being important to minimize morbidity and mortality. Underlying lung diseases are associated with ventilator-related pneumothorax with pneumothoraces occurring most commonly during the early phase of mechanical ventilation. The diagnosis of pneumothorax in critical illness is established from the patients’ history, physical examination and radiological investigation, although the appearances of a pneumothorax on a supine radiograph may be different from the classic appearance on an erect radiograph. For this reason, ultrasonography is beneficial for excluding the diagnosis of pneumothorax. Respiration-dependent movement of the visceral pleura and lung surface with respect to the parietal pleura and chest wall can be easily visualized with transthoracic sonography given that the presence of air in the pleural space prevents sonographic visualization of visceral pleura movements. Mechanically ventilated patients with a pneumothorax require tube thoracostomy placement because of the high risk of tension pneumothorax. Small-bore catheters are now preferred in the majority of ventilated patients. Furthermore, if there are clinical signs of a tension pneumothorax, emergency needle decompression followed by tube thoracostomy is widely advocated. Patients with pneumothorax related to mechanical ventilation who have tension pneumothorax, a higher acute physiology and chronic health evaluation II score or PaO₂/FiO₂ < 200 mmHg were found to have higher mortality.

Diagnosis and treatment of pneumothorax

Many diagnostic and therapeutic options exist for the evaluation and treatment of patients with pneumothorax. Guidelines from US and European professional societies and individual expert opinions differ in the approach to patient care. Advances in diagnostic techniques, such as real-time thoracic ultrasound, have added to the evaluation strategy. It is important for medical trainees and providers to become familiar with techniques utilized worldwide as they may be encountered in clinical practice. We review current evidence, expert recommendations, and compare professional society guidelines discussing the various diagnostic and management options for patients with pneumothorax to assist physicians and trainees involved in the care of hospitalized and outpatient adults who have primary, secondary, and traumatic iatrogenic pneumothorax. Management of traumatic non-iatrogenic pneumothorax is beyond the scope of this article, thus, not reviewed here.

Critical procedures in pediatric emergency medicine

Children comprise approximately one-quarter of all visits to most emergency departments. Children are generally healthier than adults, yet there are similar priorities in assessment and management of pediatric patients. The initial approach to airway, breathing, and circulation still applies and is first and foremost in the evaluation of young infants and children. There are certain anatomic, physiologic, developmental, and social considerations that are unique to this population and must be taken into account during their evaluation and treatment. In this review, we present and discuss an evidence-based approach to high-yield procedures necessary for all emergency physicians taking care of children.

Straightening out chest tubes: what size, what type, and when

Although chest tube placement is one of the most common procedures in managing patients with pleural disease, it is not clear what size and type of chest tube is indicated for various conditions. Chest tubes can be divided into small- (≤14 French [Fr]) and large-bore (>14 Fr) and can be placed by blunt dissection, guidewire (Seldinger), or trocar guidance. Recently a trend has been seen toward using smaller chest tubes for most indications, given their relative ease and patient comfort. This article summarizes the rationale for using different chest tubes depending on the clinical scenario.

Pneumothorax in the critically ill patient

Pneumothorax in critically ill patients remains a common problem in the ICU, occurring in 4% to 15% of patients. Pneumothorax should be considered a medical emergency and requires a high index of suspicion, prompt recognition, and intervention. The diagnosis of pneumothorax in the critically ill patient can be made by physical examination findings or radiographic studies including chest radiographs, ultrasonography, or CT scanning. Ultrasonography is emerging as the diagnostic procedure of choice for the diagnosis and management guidance and management of pneumothoraces, if expertise is available. Pneumothoraces in unstable, critically ill patients or in those on mechanical ventilation should be managed with tube thoracostomy. If there is suspicion for tension pneumothorax, immediate decompression and drainage should be performed. With widespread use of CT scanning, there have been more occult pneumothoraces diagnosed, and the most recent literature suggests that drainage is preferred. In patients with a persistent air leak or failure of the lung to expand, current guidelines suggest that an early thoracic surgical consultation be requested within 3 to 5 days.

Two-year experience of using pigtail catheters to treat traumatic pneumothorax: a changing trend

BACKGROUND

The traditional treatment of patients with traumatic hemopneumothorax has been an insertion of a chest tube (CT). But CT, because of its large caliber and significant trauma during an insertion, can cause pain, prevent full lung expansion, and worsen pulmonary outcome. Pigtail catheters (PCs) are smaller and less invasive; they have worked well in patients with nontraumatic pneumothorax (PTX). The purpose of this study was to review our early experience of PC use in trauma patients.

METHODS

We retrospectively reviewed the charts of trauma patients who required CT or PC placement over a 2-year period (January 2008 through December 2009) at a Level I trauma center. The PCs were 14-French (14-F) Cook catheters placed by the trauma team, using a Seldinger technique. We compared outcome for the subgroups that had CT or PC placed for a PTX. For our statistical analysis, we used the unpaired Student t-test, χ(2) test, and Wilcoxon rank-sum test; we considered a p value < 0.05 as significant.

RESULTS

Of 9,624 trauma patients evaluated, 94 were treated with PC and 386 with CT. Of the PC patients, 89% was inserted for PTX. When comparing patients with PC and CT inserted for PTX, demographics, tube days, need for mechanical ventilation, and insertion-related complications were similar. The tube failure rate, defined by a requirement for an additional tube or by recurrence that needed intervention, was higher in PC (11%) than in CT (4%) (p = 0.06), but the difference was not statistically significant. We observed a trend of increased PC use over time.

CONCLUSION

PC is safe and can be performed at the bedside. It has a comparable efficacy to CT in patients with PTX. A prospective study is needed to determine the precise role of PC placement, including its indication, the associated tube-site pain, and any significant clinical advantages.

Comparative study for the efficacy of small bore catheter in the patients with iatrogenic pneumothorax

Background

It has recently become most general to use the small bore catheter to perform closed thoracostomy in treating iatrogenic pneumothorax. This study was performed for analysis of the efficacy of treatment methods by using small bore catheter such as 7 F (French) central venous catheter, 10 F trocar catheter, 12 F pigtail catheter and for analysis of the appropriateness of each procedure.

Materials and Methods

From March 2007 to February 2010, Retrospective review of 105 patients with iatrogenic pneumothorax, who underwent closed thoracostomy by using small bore catheter, was performed. We analyzed the total success rate for all procedures as well as the individual success rate for each procedure, and analyzed the cause of failure, additional treatment method for failure, influential factors of treatment outcome, and complications.

Results

The most common causes of iatrogenic pneumothorax were presented as percutaneous needle aspiration(PCNA) in 48 cases (45.7%), and central venous catheterization in 26 cases (24.8%). The mean interval to thoracostomy after the procedure was measured as 5.2 hours (1~34 hours). Total success rate of thoracostomy was 78.1%. The success rate was not significantly difference by tube type, with 7 F central venous catheter as 80%, 10 F trocar catheter as 81.6%, and 12 F pigtail catheter as 71%. Twenty one out of 23 patients that had failed with small bore catheter treatment added large bore conventional thoracostomy, and another 2 patients received surgery. The causes for treatment failure were presented as continuous air leakage in 12 cases (52.2%) and tube malfunction in 7 cases (30%). The causes for failure did not present significant differences by tube type. Statistically significant factors affecting treatment performance were not discovered.

Conclusion

Closed thoracostomy with small bore catheter proved to be effective for iatrogenic pneumothorax. The success rate was not difference for each type. However, it is important to select the appropriate catheter by considering the patient status, pneumothorax aspect, and medical personnel in the cardiothoracic surgery department of the relevant hospital.

Pleural controversy: optimal chest tube size for drainage

In recent years, a higher and higher percentage of patients with pleural effusions or pneumothorax are being treated with small-bore (10-14 F) chest tubes rather than large-bore (>20 F). However, there are very few randomized controlled studies comparing the efficacy and complication rates with the small- and large-bore catheters. Moreover, the randomized trials that are available have flaws in their design. The advantages of the small-bore catheters are that they are easier to insert and there is less pain with their insertion while they are in place. The placement of the small-bore catheters is probably more optimal when placement is done with ultrasound guidance. Small-bore chest tubes are recommended when pleurodesis is performed. The success of the small-bore indwelling tunnelled catheters that are left in place for weeks documents that the small-bore tubes do not commonly become obstructed with fibrin. Patients with complicated parapneumonic effusions are probably best managed with small-bore catheters even when the pleural fluid is purulent. Patients with haemothorax are best managed with large-bore catheters because of blood clots and the high volume of pleural fluid. Most patients with pneumothorax can be managed with aspiration or small-bore chest tubes. If these fail, a large-bore chest tube may be necessary. Patients on mechanical ventilation with barotrauma induced pneumothoraces are best managed with large-bore chest tubes.