Is a chest radiograph after thoracostomy tube removal necessary? A cost-effective analysis

Timing of ultra-portable ultrasound (UPUS) Examinations in detecting clinically concerning recurrent pneumothorax

BACKGROUND

Recurrent pneumothorax (rPTX) is a common complication following thoracostomy tube (TT) removal in chest trauma patients. While chest X-ray (CXR) is most commonly used to detect a rPTX, bedside ultraportable ultrasound (UPUS) is a feasible, low cost, and radiation free alternative. No consensus exists with regards to the optimal timing of diagnostic imaging to assess for rPTX post-TT removal. Accordingly, we sought to identify an ideal UPUS timing to detect a rPTX METHODS: We conducted a single center prospective study of adult (≥18years) patients admitted with a chest trauma. UPUS examinations were performed using the Butterfly iQ+™ ultrasound. Three intercostal spaces (ICS) were evaluated (2nd through 4th). Post-TT UPUS examinations were performed at different timepoints following tube removal (1-6 h). A rPTX on UPUS was defined as the absence of lung-sliding in one or more intercostal spaces, and was considered a clinically concerning rPTX if lung-sliding was absent in ≥2 ICS. UPUS findings were compared to CXR.

RESULTS

Ninety-two patients (97 hemi-thoraces) were included in the analysis. A total of 58 patients had a post-TT removal rPTX of which 11 were either clinically concerning or expanding. Comparing UPUS findings to CXR, the 3-hour post-TT removal ultrasound examinations were associated with the highest sensitivity. By hour 4, no rPTX showed expansion in size. Three patients required an intervention for a clinically concerning rPTX, all of whom were detected on UPUS 3-hour post-TT removal.

CONCLUSION

Bedside UPUS performed at 3-hour post-TT removal has the highest sensitivity in detecting clinically concerning rPTX. Size of rPTX appears to stabilize by hour 4. In the absence of clinical symptoms, repeat imaging or observation of non-significant rPTX beyond 4 h may not provide added clinical benefit.

LEVEL OF EVIDENCE

Level II, Diagnostic Tests or Criteria.

A single-centre retrospective study of the utility of routine chest X-ray post intrathoracic drain removal in cardiothoracic surgical patients

Routine chest X-ray (CXR) post intrathoracic drain removal in cardiac surgical patients is common practice to identify the presence of a pneumothorax following drain removal. Such pneumothoraces occur infrequently and rarely require intervention. We investigated the utility of routine CXR post drain removal and hypothesised that the practice is unnecessary and a possible area for significant cost saving. We conducted a single-centre, retrospective study of 390 patients who underwent cardiac surgery over a one-year period. Routine CXR post drain removal was reviewed for the presence of a pneumothorax. Rates of intervention post routine CXR were analysed to assess for clinical benefit obtained from this practice. Potential cost savings were calculated by the cost of a mobile CXR and by considering the radiographer's time. There were 15 pneumothoraces detected on routine CXR post drain removal. All pneumothoraces detected on routine post drain removal CXR were defined as small. No patients had a clinically significant pneumothorax requiring re-insertion of a chest drain. The potential cost saved by omitting routine CXR post drain removal was estimated to be approximately A$7750 per year. This study did not detect any clinically significant pneumothoraces requiring intervention. It also suggests that routine CXR post drain removal does not provide any clinical benefit and indicates that current practice should be reviewed.

The value of chest radiography after chest tube removal in nonventilated trauma patients: A post hoc analysis of a multicenter prospective cohort study

BACKGROUND

Chest tubes are commonly placed in trauma care to treat life-threatening intrathoracic injuries by evacuating blood or air from the pleural cavity. Currently, it is common practice to routinely obtain chest radiographs between 1 to 8 hours after chest tube removal, while the necessity of it has been questioned. This study describes the "ins-and-outs" of chest tubes and evaluates the value of routine postremoval chest radiography in nonventilated trauma patients.

METHODS

A post hoc analysis of a multicenter observational prospective cohort study was performed in blunt chest trauma patients admitted with multiple rib fractures to two level 1 trauma centers between January 2018 and March 2021 and treated with one or more chest tubes. Exclusion criteria were mechanical ventilation during chest tube removal, missing reports of postremoval chest radiography, transfer to another hospital, or mortality before chest tube removal. Descriptive analyses were performed to calculate the number of findings on postremoval chest radiographs and reinterventions.

RESULTS

A total of 207 patients were included for analysis of whom 14 underwent bilateral chest tube placement, resulting in 221 chest tube removals investigated in this study. The mean ± SD age was 58 ± 17 years, 71% were male, 73% had American Society of Anesthesiologists scores of 1 or 2, and the median Injury Severity Score was 19 (interquartile range, 14-29). In 68 of 221 chest tube removals (31%), postremoval chest radiography showed increased or recurrent intrathoracic pathology (i.e., 13% pneumothorax, 18% pleural fluid, and 8% atelectasis). Only two (3%) of these patients underwent a same-day reintervention based on these findings, of whom one had signs or symptoms of recurrent pathology and one was asymptomatic.

CONCLUSION

It seems safe to omit routine use of postremoval chest radiography in nonventilated blunt chest trauma patients and to selectively use imaging in those patients presenting with clinical signs or symptoms after chest tube removal.

LEVEL OF EVIDENCE

Diagnostic Tests/Criteria; Level IV.

Routine chest radiography after thoracostomy tube removal and during postoperative follow-up is not necessary after lung resection

OBJECTIVES

The need for routine chest radiography following chest tube removal after elective pulmonary resection may be unnecessary in most patients. The purpose of this study was to determine the safety of eliminating routine chest radiography in these patients.

METHODS

Patients who underwent elective pulmonary resection, excluding pneumonectomy, for benign or malignant indications between 2007 and 2013 were reviewed. Patients with in-hospital mortality or without routine follow-up were excluded. During this interval, our practice transitioned from ordering routine chest radiography after chest tube removal and at the first postoperative clinic visit to obtaining imaging based on symptomatology. The primary outcome was changes in management from results of chest radiography obtained routinely versus for symptoms. Characteristics and outcomes were compared using the Student t test and chi-square analyses.

RESULTS

A total of 322 patients met inclusion criteria. Ninety-three patients underwent a routine same-day post-pull chest radiography, and 229 patients did not. Thirty-three patients (14.4%) in the nonroutine chest radiography cohort received imaging for symptoms, in whom 8 (24.2%) resulted in management changes. Only 3.2% of routine post-pull chest radiography resulted in management changes versus 3.5% of unplanned chest radiography with no adverse outcomes (P = .905). At outpatient postoperative follow-up, 146 patients received routine chest radiography; none resulted in a change in management. Of the 176 patients who did not have planned chest radiography at follow-up, 12 (6.8%) underwent chest radiography for symptoms. Two of these patients required readmission and chest tube reinsertion.

CONCLUSIONS

Reserving imaging for patients with symptoms after chest tube removal and follow-up after elective lung resections resulted in a higher percentage of meaningful changes in clinical management.

Ultrasound may safely replace chest radiograph after tube thoracostomy removal in trauma patients

INTRODUCTION

A chest radiograph (CXR) is routinely obtained in trauma patients following tube thoracostomy (TT) removal to assess for residual pneumothorax (PTX). New literature supports the deference of a radiograph after routine removal procedure. However, many surgeons have hesitated to adopt this practice due to concern for patient welfare and medicolegal implications. Ultrasound (US) is a portable imaging modality which may be performed rapidly, without radiation exposure, and at minimal cost. We hypothesized that transitioning from CXR to US following TT removal in trauma patients would prove safe and provide superior detection of residual PTX.

MATERIALS AND METHODS

A practice management guideline was established calling for the performance of a CXR and bedside US 2 h after TT removal in all adult trauma patients diagnosed with PTX at a level 1 trauma center. Surgical interns completed a 30-minute, US training course utilizing a handheld US device. US findings were interpreted and documented by the surgical interns. CXRs were interpreted by staff radiologists blinded to US findings. Data was retrospectively collected and analyzed.

RESULTS

Eighty-nine patients met inclusion criteria. Thirteen (15%) post removal PTX were identified on both US and CXR. An additional 11 (12%) PTX were identified on CXR, and 5 (6%) were identified via US, for a total of 29 PTX (33%). One patient required re-intervention; the recurrent PTX was detected by both US and CXR. For all patients, using CXR as the standard, US displayed a sensitivity of 54.2%, specificity of 92.3%, negative predictive value of 84.5%, and positive predictive value of 72.2%. The cost of care for the study cohort may have been reduced over $9,000 should US alone have been employed.

CONCLUSION

Bedside US may be an acceptable alternative to CXR to assess for recurrent PTX following trauma TT removal.

Are Routine Chest Radiographs After Chest Tube Removal in Thoracic Surgery Patients Necessary?

INTRODUCTION

The routine use of chest x-ray (CXR) to evaluate the pleural space after chest tube removal is a common practice driven primarily by surgeon preference and institutional protocol. The results of these postpull CXRs frequently lead to additional interventions that serve only to increase health care costs and resource utilization. We investigated the utility of these postpull CXRs in thoracic surgery patients and assessed their effectiveness in predicting the need for tube replacement.

METHODS

Single-institution retrospective study comprising thoracic surgery patients requiring postoperative chest tube drainage over a 3-y period. Demographics and surgical characteristics, including surgical approach, procedure, and procedure type, were recorded. Outcomes included postpull CXR findings, interventions resulting from radiographic abnormalities, and the additional health resource utilization incurred by obtaining these studies on asymptomatic patients.

RESULTS

The study included 433 patients. Postpull CXRs were performed in 87.1% of patients, with 33.2% demonstrating an abnormality compared with the prior study. Among these, 65.7% resulted only in repeat imaging and 25.7% resulted in discharge delay. Overall, a total of 13 patients (3%) required chest tube replacement, three during the index hospitalization and the other 10 requiring readmission. Among those requiring chest tube replacement, 75% had normal postpull imaging, and all were symptomatic.

CONCLUSIONS

Recurrent pneumothorax after chest tube removal requiring immediate tube reinsertion is relatively rare and does not occur in the absence of symptoms. Our study suggests that routine postpull CXRs have limited clinical utility and can be safely omitted in asymptomatic patients with appropriate clinical observation.

Scoping review of traumatic hemothorax: Evidence and knowledge gaps, from diagnosis to chest tube removal

BACKGROUND

Traumatic hemothorax is a common injury that invites diagnostic and management strategy debates. Evidence-based management has been associated with improved care efficiency. However, the literature abounds with long-debated, re-emerging, and new questions. We aimed to consolidate up-to-date evidence on traumatic hemothoraces, focusing on clinical conundra debated in literature.

METHODS

We conducted a scoping review of 21 clinical conundra in traumatic hemothorax diagnosis and management according to PRISMA-ScR guidelines. Experimental and observational studies evaluating patients (aged ≥18 years) with traumatic hemothoraces were identified through database searches (PubMed, EMBASE, Web of Science, Cochrane Library; database inception to Sep, 26 2020) and bibliography reviews of selected articles. Three reviewers screened and selected articles using standardized forms.

RESULTS

We screened 1,440 articles for eligibility, of which 71 met criteria for synthesis. The review comprises 6 sections: (1) Presumptive antibiotics before tube thoracostomy; (2) Initial diagnostic and intervention decisions; (3) Chest tubes; (4) Retained hemothoraces; (5) Delayed hemothoraces; and (6) Chest tube removal). The 21 conundra across these sections follow the format of a question, our recommendation based on interpretation of available evidence, and succinct rationale. Rationale sections detail knowledge gaps and opportunities for future research.

CONCLUSION

Even practices engrained into surgical dogma, such as obtaining chest x-rays after inserting or removing chest tubes and mandating operation for patients who develop chest tube output above a certain threshold, deserve re-evaluation. Some knowledge gaps require rigorous future investigation; sound clinical judgment can likely supplement others.