Effectiveness of chest tube evacuation of pneumothorax in neonates

Lung Perforation by Chest Tubes in the Neonate

In 272 consecutive neonatal autopsies in one institution, 70 patients had had intercostal drainage tubes inserted to treat air leak secondary to pulmonary disease. In 9 of these cases, one or more chest tubes penetrated lung parenchyma. The majority of these occurred in infants less than 36 weeks' gestation with hyaline membrane disease and its sequelae. Laceration of lung parenchyma most commonly occurred when tubes were inserted on the left side at 5 days or later and when multiple tubes were inserted.

Unsuspected transection of lung by pigtail catheter in a premature infant

Thoracostomy tubes are commonly required to treat pnuemothoraces in premature infants. Evidence of impalement of the lungs by tube thoracostomy has been seen in autopsy studies. In neonates, there has been described a surprisingly high incidence of lung perforation. The premature lung is thought to be at greater risk for this complication owing to the pliant, thin chest wall, the proximity of vital tissues and the fragility of the lung tissue itself. The modified Fuhrman catheter, or polyurethane pigtail catheter, has been developed for the drainage of pneumothorax in premature infants. In a study of complications of the placement of pigtail catheters, no instance of penetration of the lungs was reported. We report the case of a premature infant with pigtail catheter placement that, at autopsy, was found to have impaled the lung and discuss the incidence of lung injury associated with invasive management of pnuemothoraces.

[Comparative study of different methods of pleural drainage in an experimental model of pneumothorax]

OBJECTIVE

To observe the usefulness of several procedures for draining pneumothorax in an animal model and to identify the best pleural drainage system with minimal impairment of respiratory function.

METHOD

Thirty-four New Zealand white rabbits weighting 1687 +/- 78 g and aged a mean 59 days were randomly placed in groups as follows. Unilateral pneumothorax was induced in the first problem group (P1) rabbits (n = 10) by thoracostomy, with pleural drainage. In the second problem group (P2) of rabbits (n = 10), bilateral pneumothorax was similarly induced by thoracostomy with pleural drainage. The control groups underwent unilateral (C1; n = 7) and bilateral (C2; n = 7) thoracostomy and drainage. Every 7 minutes the chest tube was connected successfully in each animal to an underwater seal with a dead-space volume of 35.58 ml (neonatal Bülau unit) or to a 3,940 ml system (chest drainage unit) and to pleural aspirations of -5 and -20 cmH2O. We analyzed mortality, fluctuations of the hydrostatic column of the underwater seal, heart rate (HR), respiratory rate (RR), PaCO2, SaO2, pH and arterial blood gas measures.

RESULTS

Intraoperative mortality was significantly higher (particularly in the P2 group) when connection was to a large volume system without aspiration. Recovery after pneumothorax was more satisfactory with aspiration of -5 and -20 cmH2O.

CONCLUSIONS

The results suggest that a pleural drainage unit with a large dead space between the pleural cavity and the underwater seal is a frequent cause of respiratory failure or insufficiency. We believe that when an underwater seal without pleural suction is applied, the Bülau unit should be used with the smallest possible volume.

Selective use of chest tubes in thoracotomies for congenital cardiovascular procedures

BACKGROUND

Advantages and complications have been reported from the use of chest tubes (CT). To reduce the incidence of complications we have employed a selective use of CT in thoracotomy for congenital cardiovascular procedure; ie, in absence of air leaks and fluid to be drained, no CT was inserted.

METHODS

The lung was reexpanded and air evacuated during the chest closure. Early and 6 hours chest roentgenograms were performed on every patient. This study retrospectively reviews the results of this selective approach in 546 patients operated on between 1980 and 1998 mainly for patent ductus arteriosum ligation, pulmonary artery band, aortic coarctation, Blalock-Taussig shunt. Four hundred and eighteen patients did not receive a CT at the initial surgery (group I), and 128 patients received a CT either before or at surgery (group II).

RESULTS

40 patients in group I developed an air or fluid collection large enough to require a CT. Only one patient had complication, from an undetected hemothorax. Nine patients in group II required another CT, and one patient developed a pneumothorax upon pulling out the CT. No death in either group was related to the use or lack of use of the CT. A total of 378 CTs and collecting chambers were saved.

CONCLUSIONS

A selective approach to the use of CT in thoracotomies for cardiovascular procedures can be employed with minimal complications, more comfort for the patient, and cost savings.

Efficacy and complications of percutaneous pigtail catheters for thoracostomy in pediatric patients

OBJECTIVE

To describe the efficacy of percutaneous pigtail catheters in evacuating pleural air or fluid in pediatric patients.

DESIGN

A case series of children with percutaneous pigtail catheters placed in the pediatric ICU between January 1996 and August 1997.

SETTING

Urban pediatric teaching hospital in Seattle, WA.

METHODS

A retrospective chart review.

RESULTS

Ninety-one children required 133 chest catheters. Most patients were infants with congenital heart disease (80%). One hundred thirteen of the catheters (85%) were placed for pleural effusion, with 20 tubes (15%) placed for pneumothorax. Efficacy of drainage of pleural fluid was significantly greater in serous (96%) and chylous (100%) effusions compared with empyema (0%) or hemothorax (81%). Evacuation of pneumothorax was achieved by a pigtail catheter in 75% of patients. Resolution of pleural air or pneumothorax was significantly greater in patients < 10 kg compared with larger children. Complications due to placement of the pigtail catheters included hemothorax (n=3, 2%), pneumothorax (n=3, 2%), and hepatic perforation (n= 1, 1%). There were also complications arising from the use of the catheters, including failure to drain, dislodgment, kinking, loss of liquid ventilation fluid, empyema, and disconnection in 27 of 133 catheters (20%). Significantly more complications during catheter use occurred in patients <5 kg than in larger children.

CONCLUSIONS

Percutaneous pigtail catheters are highly effective in drainage of pleural serous and chylous effusions, somewhat less efficacious in drainage of hemothorax or pneumothorax, and least efficacious in drainage of empyema. Infants and smaller children had higher rates of resolution of pleural air and fluid from placement of a pigtail catheter than larger children. Complications from catheter placement were uncommon (5%) but serious, whereas complications associated with continued use of the catheters were more common (20%) but less grave. Strict attention to anatomic landmarks and close monitoring may reduce the number of complications.

Pneumothorax in the neonate

Neonatal critical-care nurses frequently care for neonates experiencing pneumothoraces. The treatment of a pneumothorax varies with the cause. Knowledge of the condition will help the nurse in caring for the neonate at high risk. In this article, types of pneumothoraces will be reviewed, and information will be provided regarding the pathophysiology, diagnosis, treatment, and nursing responsibilities in caring for an infant experiencing a pneumothorax.

Chest tubes: indications, placement, management, and complications

Use of tube thoracostomy in intensive care units for evacuation of air or fluid from the pleural space has become commonplace. In addition to recognition of pathological states necessitating chest tube insertion, intensivists are frequently involved in placement, maintenance, troubleshooting, and discontinuation of chest tubes. Numerous advances have permitted safe use of tube thoracostomy for treatment of spontaneous or iatrogenic pneumothoracies and hydrothoracies following cardiothoracic surgery or trauma, or for drainage of pus, bile, or chylous effusions. We review current indications for chest tube placement, insertion techniques, and available equipment, including drainage systems. Guidelines for maintenance and discontinuation are also discussed. As with any surgical procedure, complications may arise. Appropriate training and competence in usage may reduce the incidence of complications.

An expansible cannula: a new technique for chest drain insertion

The insertion of a chest drain into the pleural space is a common procedure used by many specialties. The commonly used device is a prepacked, sterile plastic tube with its own central metal trocar. Complications may arise during its insertion, with the occasional penetration of intrathoracic and upper abdominal organs. As most chest drains are inserted by junior and relatively inexperienced doctors, it is therefore imperative that a simple, safe, and effective technique of insertion is found. A device has been developed that consists of a 5 cm conical length of an expansible cannula, made from rolled metal foil, which when inserted into the chest reaches only a few millimetres within the pleura. When an expander tube, 10 mm in diameter, is passed through the device from its proximal end the conical tube is distended into a hollow cylindrical one, through which a standard Portex chest catheter is passed. The whole appliance is then removed over the end of the tube, leaving the drain in situ. The efficacy of this unique device has been tested in a pilot study in 22 patients. There have been no complications.

Clinical evaluation of a new chest tube used in neonates

We report preliminary experience with a newly designed chest tube (JCT), for evacuation of neonatal pneumothorax. The catheter has a unique pigtail confirguration at the distal end, intended to simplify placement and minimize chest wall and lung trauma by reduced tube size and depth and insertion. Thirty-eight JCTs were placed in neonates with pneumothoraces. Neonates' birth weights ranged from 400 to 3,595 grams. All 38 tubes immediately relieved clinical signs of pneumothoraces. Thirty-five (92%) tubes immediately fully evacuated the pneumothoraces as evidences on chest radiograph. Twelve pneumothoraces partially reoccurred at a mean of 24 hours following JCT placement. These tubes were either irrigated or replaced. This newly configured chest tube functions effectively in the treatment of neonatal pneumothorax.

The scars of newborn intensive care

Many techniques used in neonatal intensive care are invasive and the risk of producing skin damage is high. To investigate this, 100 consecutive survivors of neonatal intensive care (gestation 26-42 weeks, median 32) were examined in detail by a single observer at 16-29 months of age, and the scar severity, site and likely cause noted. Scarring was present in all infants although it was usually trivial. The total number of scars was inversely related to gestational age and directly related to the duration of intensive care. Eleven children had cosmetically or functionally significant lesions caused by chest drain insertion, extravasation of intravenous fluid or skin stripping by adhesive tape. To reduce the frequency and severity of skin damage, neonatal staff need to be aware that many routine procedures may lead to long term scarring. In particular, more careful wound closure after chest drain removal is needed.

Neonatal pneumothorax drainage systems: in vitro evaluation

We studied, in vitro, different commercially available components for pneumothorax drainage, i.e. drainage tubes, Heimlich flutter valve and vacuum control units. The drainage of a pneumothorax by a drainage tube was, as expected, directly dependent on Poiseuille's law and was influenced more by diameter than length. Of practical importance, a size 6 French gauge tube, used for the very small newborn, may not efficiently evacuate a pneumothorax due to a large air leak. The Heimlich flutter valve, though useful clinically, adds to the resistance of the system especially if fluids accumulate in the valve. All vacuum control units, adaptations of the basic three- or four-bottle pleural drainage system, functioned adequately but simple changes in construction may increase the safety of some of these systems.