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

A Randomized Non-Inferiority Clinical Trial of 14Fr Thal versus 28Fr Tube Thoracostomy for Traumatic Hemothorax

BackgroundThe traditional treatment of traumatic hemothorax (HTX) is large bore chest tubes (CT) ≥28Fr. Recent evidence shows 14Fr pigtail catheters are as effective in drainage of HTX as larger CT. However, this has not been shown in 14Fr Thal tubes, a straight chest tube placed utilizing Seldinger technique.MethodsA single center, prospective randomized controlled trial was performed at an ACS verified Level 1 trauma center comparing 14Fr Thal CT (14CT) to 28Fr CT (28CT) between May 2017 and September 2021. The primary outcome was failure of drainage of hemothorax requiring additional intervention. Secondary outcomes included duration of chest tube placement, length of stay, tube-specific complications, and 90-day hospital readmission. Farrington-Manning approach was used for non-inferiority tests. Wilcoxon 2-samples test or t test was used for continuous variables, and Pearson chi-square or Fisher exact test was used for categorical variables.Results109 patients were included in the randomized trial. There were 54 patients in the 14CT cohort, and 55 patients in the 28CT cohort. The primary outcome of drainage failure was similar between groups (8.3% 14CT vs 3.9% 28CT). Using a 15% non-inferiority margin 14CT is non-inferior to 28CT. No differences were identified in secondary outcomes.Conclusion14Fr Thal tubes have similar efficacy in drainage of traumatic hemothorax when compared with 28Fr chest tubes with similar complication rates (NCT03167723).

Ultrasound-guided small-bore chest drain placement: a retrospective analysis of feasibility, safety and clinical implications in internal medicine ward

PURPOSE

Massive and complex pleural effusions represent a frequent challenge for internists, particularly when patients present with significant symptoms and the hospital setting lacks dedicated thoracic surgery or interventional pneumology services.

METHODS

This retrospective study evaluates the effectiveness and feasibility of ultrasound-guided small-bore chest drain placement performed by internal medicine physicians with interventional ultrasound experience. We analyze procedural success rates, complication profiles, and subsequent clinical management in a cohort of patients managed in a single internal medicine ultrasound ward.

RESULTS

In our series of ten patients, ultrasound-guided drain placement was successful in all cases. No immediate major complications were encountered, and subsequent complications were minimal and manageable.

CONCLUSION

Ultrasound-guided small-bore chest drain placement is a feasible, safe, and effective alternative to surgical chest tube insertion in selected patients in internal medicine wards, potentially avoiding the need for hospitalization or transfer to specialized thoracic surgery services.

Thoracic irrigation for traumatic hemothorax: A systematic review and meta-analysis

BACKGROUND

Traumatic hemothoraces (HTXs) are common, and tube thoracostomy (TT) insertion is generally the initial management. However, a retained HTX can develop into a fibrothorax or empyema requiring secondary intervention. We hypothesized that irrigation of the thoracic cavity at the time of TT may prevent retained HTX.

METHODS

Pubmed, EMBASE, and Scopus were searched from inception to May 2024. Studies with adult trauma patients with traumatic HTX who received a TT and had patients who underwent thoracic irrigation were included. The primary outcome was failure rate, defined as retained HTX requiring a second intervention. Cumulative analysis was performed with χ 2 for dichotomous variables and unpaired t test for continuous variables. A fixed-effects model was applied for meta-analysis.

RESULTS

Six studies were included in the analysis; two retrospective and four prospective observational studies. These studies included 1,319 patients (513 irrigated TT, 837 nonirrigated TT). The mean age of patients was 45 years, 81% were male, mean Injury Severity Score was 21, and 42% had penetrating trauma. Failure rate was significantly lower in the irrigation group on cumulative analysis (10.7% vs. 18.2%, p < 0.001) and meta-analysis (effect size, 0.704; 95% confidence interval, 0.218-1.190; I2 = 0.4; p < 0.001]. In addition, on meta-analysis, the irrigation group had a shorter TT duration and hospital and ICU length of stay (all p < 0.05). There were no differences in overall infectious complications, readmission, or mortality; however, all the models favored the irrigation group.

CONCLUSION

Patients who undergo simultaneous TT and thoracic irrigation have a lower rate of retained HTX and require fewer secondary interventions. Thoracic irrigation for traumatic HTX should be considered; however, randomized studies are needed prior to development of guidelines.

LEVEL OF EVIDENCE

Systematic Review/Meta-analysis; Level III.

Pleural Space Management in Thoracic Trauma

SUMMARY

Thoracic injuries are common, occurring in up to 60% of polytrauma patients and represent 25% of trauma deaths. Thoracic trauma frequently involves injury to the pleural space resulting in hemothorax and pneumothorax-effective management of the pleural space is essential. Reviewed in this article is management of the pleural space in chest wall trauma (including pneumothorax and hemothorax), and chest tube placement, indications for video-assisted thoracoscopic surgery, management, and complications.

The size paradox: An analysis of tube thoracostomy in trauma

BACKGROUND

Debate 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).

METHODS

A 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.

RESULTS

Of 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).

CONCLUSIONS

This 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.

Postoperative Drainage Efficacy of 8Fr Pigtail Catheter After Bullectomy: A Non-Inferiority Study

Background There are no established guidelines regarding the optimal size of chest tubes following a bullectomy. While large chest tubes are commonly used after bullectomy, several studies have shown that pigtail catheters can be effectively employed for postoperative drainage in lung cancer surgery. This study aimed to compare the time to tube removal between an 8Fr pigtail catheter and a 24Fr chest tube after bullectomy to assess the non-inferiority of the 8Fr pigtail catheter. Methods Data from 32 patients aged 14-30 years who underwent bullectomy between April 2020 and April 2023 were analyzed. Participants were assigned to receive either an 8Fr pigtail catheter (n = 10) or a 24Fr chest tube (n = 22). The primary outcome measured was the number of days until tube removal. Results The mean time to tube removal was 1.2 days in the 8Fr group and 1.5 days in the 24Fr group, meeting the non-inferiority margin of one day (mean difference: -0.3 days, 95% CI: -0.78, 0.18). No major complications were observed in either group. Conclusions An 8Fr pigtail catheter appears to be a non-inferior alternative to the 24Fr chest tube for postoperative drainage following bullectomy.

Role of low-pressure negative pleural suction in patients with thoracic trauma - a randomized controlled trial

BACKGROUND

Thoracic trauma frequently includes a pneumothorax, hemothorax, or hemopneumothorax, which may necessitate an Intercostal drainage (ICD) for air and fluid evacuation to improve breathing and circulatory function. It is a simple and life-saving procedure; nevertheless, it carries morbidity, even after its removal. Efforts have been made continuously to shorten the duration of ICD, but mostly in non-trauma patients. In this study, we evaluated the impact of negative pleural suction over the duration of ICD.

METHODS

This study was a prospective randomized controlled interventional trial conducted at Level 1 Trauma Centre. Thoracic trauma patients with ICD, who met the inclusion criteria (sample size 70) were randomized into two groups, the first group with negative pleural suction up to -20 cm H2O, and the second group as conventional, i.e. ICD connected to underwater seal container only. The primary objective was to compare the duration of ICDs and the secondary objectives were the length of hospital stay and various complications of thoracic trauma.

RESULTS

Duration of ICD was measured in median days with minimum & maximum days. For the negative suction group, it was 4 days (2-16 days); for the conventional group, it was also 4 days (2-17 days). There was also no significant difference among both groups in length of hospital stay.

CONCLUSION

The beneficial effect of negative pleural suction to ICD could not be demonstrated over the duration of ICD and hospital stay. In both groups, there was no significant difference in complication rates like recurrent pneumothorax, retained hemothorax, persistent air leak, and empyema.

LEVEL OF EVIDENCE

Therapeutic Study, Level II TRIAL REGISTRATION: This trial was registered with the Clinical Trial Registry of India (CTRI) with registration no. REF/2020/11/038403.

Small versus large-bore thoracostomy for traumatic hemothorax: A systematic review and meta-analysis

BACKGROUND

Traumatic hemothorax (HTX) is common, and while it is recommended to drain it with a tube thoracostomy, there is no consensus on the optimal catheter size. We performed a systematic review to test the hypothesis that small bore tube thoracostomy (SBTT) (≤14 F) is as effective as large-bore tube thoracostomy (LBTT) (≥20F) for the treatment of HTX.

METHODS

Pubmed, EMBASE, Scopus, and Cochrane review were searched from inception to November 2022 for randomized controlled trials or cohort studies that included adult trauma patients with HTX who received a tube thoracostomy. Data was extracted and Critical Appraisal Skills Program checklists were used for study appraisal. The primary outcome was failure rate, defined as incompletely drained or retained HTX requiring a second intervention. Cumulative analysis was performed with χ 2 test for dichotomous variables and an unpaired t-test for continuous variables. Meta-analysis was performed using a random effects model.

RESULTS

There were 2,008 articles screened, of which nine were included in the analysis. The studies included 1,847 patients (714 SBTT and 1,233 LBTT). The mean age of patients was 46 years, 75% were male, average ISS was 20, and 81% had blunt trauma. Failure rate was not significantly different between SBTT (17.8%) and LBTT (21.5%) ( p = 0.166). Additionally, there were no significant differences between SBTT vs. LBTT in mortality (2.9% vs. 6.1%, p = 0.062) or complication rate (12.3% vs. 12.5%, p = 0.941), however SBTT had significantly higher initial drainage volumes (753 vs. 398 mL, p < 0.001) and fewer tube days (4.3 vs. 6.2, p < 0.001). There are several limitations. Some studies did not report all the outcomes of interest, and many of the studies are subject to selection bias.

CONCLUSION

SBTT may be as effective as LBTT for the treatment of traumatic HTX.

LEVEL OF EVIDENCE

Systematic Review/Meta-Analysis; Level IV.

The role of video-assisted thoracoscopy in chest trauma: a retrospective monocentric experience

Video-assisted thoracoscopy (VAT) plays an essential role in the exploration of pleural cavity after thoracic trauma, although some doubts about the precise and specific indications persist. This study examines the eligibility criteria for videothoracoscopy and establishes the ideal timing for VAT. Between January 2011 and November 2022, we observed 923 polytraumatized patients. All patients underwent computed tomography (CT) scan total body with and without contrast enhancement. Two hundred and nine patients carried out VAT within 10 ± 2 h of injury while 8 patients after 20 ± 1 h. The Injury Severity Score (ISS) was 31 ± 1 and the Glasgow Coma Scale was 14.1 ± 0.3 upon arrival at the hospital. One hundred and nineteen patients displayed hemothorax (55%), 62 hemopneumothorax (28.5%), 21 penetrating wound (9.6%), 10 pneumothorax (4.6%) and 5 chylothorax (2.3%). In 18 patients (8.3%) without vascular, diaphragmatic, or parenchymal lesion the treatment consisted in chest tube placement. VAT was converted to video-assisted thoracoscopic surgery (VATS) in 190 patients (87.5%), to open surgery in 8 (3.7%) and to laparoscopy in 1 (0.5%). Twelve patients (5.5%) with diaphragm ruptures < 5 cm in diameter were treated by separate stitches suture in VATS. Only eight postoperative complications (4 pneumonia, three atelectasis and one pulmonary embolism) out of 217 VAT, positively resolved with medical treatment, were noted exclusively in patients undergoing minimally invasive approach 20 ± 1 h after trauma. Early VAT in selected patients is a safe and easy procedure that ensure a quick diagnosis of lesions and an accurate management of the most thoracic injuries among trauma patients. The prompt identification of injuries, to avoid life-threatening conditions requiring rapid intervention, responds to medico-legal needs to which VAT fulfills.

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

INTRODUCTION

 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.

MATERIALS AND METHODS

 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.

RESULTS

 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.

CONCLUSION

 PGC is an effective, safe, and less painful alternative compared with a LBC for the drainage of SPT in children.

Thoracic cavity irrigation prevents retained hemothorax and decreases surgical intervention in trauma patients

INTRODUCTION

Retained hemothorax (HTX) is a common complication following thoracic trauma. Small studies demonstrate the benefit of thoracic cavity irrigation at the time of tube thoracostomy (TT) for the prevention of retained HTX. We sought to assess the effectiveness of chest irrigation in preventing retained HTX leading to a secondary surgical intervention.

METHODS

We performed a single-center retrospective study from 2017 to 2021 at a Level I trauma center, comparing bedside thoracic cavity irrigation via TT versus no irrigation. Using the trauma registry, patients with traumatic HTX were identified. Exclusion criteria were TT placement at an outside hospital, no TT within 24 hours of admission, thoracotomy or video-assisted thoracoscopic surgery (VATS) prior to or within 6 hours after TT placement, VATS as part of rib fixation or diaphragmatic repair, and death within 96 hours of admission. Bivariate and multivariable analyses were conducted.

RESULTS

A total of 370 patients met the inclusion criteria, of whom 225 (61%) were irrigated. Patients who were irrigated were more likely to suffer a penetrating injury (41% vs. 30%, p = 0.03) and less likely to have a flail chest (10% vs. 21%, p = 0.01). On bivariate analysis, irrigation was associated with lower rates of VATS (6% vs. 19%, p < 0.001) and retained HTX (10% vs. 21%, p < 0.001). The irrigated cohort had a shorter TT duration (4 vs. 6 days, p < 0.001) and hospital length of stay (7 vs. 9 days, p = 0.04). On multivariable analysis, thoracic cavity irrigation had lower odds of VATS (adjusted odds ratio, 0.37; 95% confidence interval [CI], 0.30-0.54), retained HTX (adjusted odds ratio, 0.42; 95% CI, 0.25-0.74), and a shorter TT duration ( β = -1.58; 95% CI, -2.52 to -0.75).

CONCLUSION

Our 5-year experience with thoracic irrigation confirms findings from smaller studies that irrigation prevents retained HTX and decreases the need for surgical intervention.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

[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.

Thoracic Lavage for Traumatic Hemothorax

This Surgical Innovation discusses thoracic lavage for traumatic hemothorax.

Minimally invasive management of thoracic trauma: current evidence and guidelines

Minimally invasive procedures are being increasingly proposed for trauma. Injuries to the chest wall and/or lung have historically been managed by drainage with a large bore thoracostomy tube, while cardiac injuries have mandated sternotomy. These treatments are associated with significant patient discomfort. Percutaneous placement of small 'pigtail' catheters was initially designed for drainage of simple pericardial fluid. Their use subsequently expanded to drainage of the pleural cavity. The role of pigtail catheters for primary treatment of traumatic pneumothorax and hemopneumothorax has increased, while their use for pericardial fluid after trauma remains controversial. Pericardial windows have alternatively been purposed as a minimally invasive treatment option for possible hemopericardium. The aim of this article is to review the current evidence and guidelines for minimally invasive management of chest trauma.

Chest Tube Size Selection: Evaluating Provider Practices, Treatment Efficacy, and Complications in Management of Thoracic Trauma

BACKGROUND

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.

METHODS

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.

RESULTS

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.

DISCUSSION

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.

Management of Blunt Chest Trauma

Common mechanisms of blunt thoracic injury include motor vehicle collisions and falls. Chest wall injuries include rib fractures and sternal fractures; treatment involves supportive care, multimodal analgesia, and pulmonary toilet. Pneumothorax, hemothorax, and pulmonary contusions are also common and may be managed expectantly or with tube thoracostomy as indicated. Surgical treatment may be considered in select cases. Less common injury patterns include blunt trauma to the tracheobronchial tree, esophagus, diaphragm, heart, or aorta. Operative intervention is more often required to address these injuries.

Percutaneous thoracostomy with thoracic lavage for traumatic hemothorax: a performance improvement initiative

Objectives

Percutaneously placed small-bore (14 Fr) catheters and pleural lavage have emerged independently as innovative approaches to hemothorax management. This report describes techniques for combining percutaneous thoracostomy with pleural lavage and presents results from a performance improvement series of patients managed with percutaneous thoracostomy with immediate lavage.

Methods

This was a prospective performance improvement series of patients treated at a level 1 trauma center with percutaneous thoracostomy and immediate lavage between April 2021 and May 2023.

Results

Percutaneous thoracostomy with immediate lavage was used to treat nine hemodynamically normal patients with acute hemothorax. Injuries included both blunt and penetrating mechanisms. 56% of patients presented immediately after injury, and 44% presented in a delayed fashion ranging from 2 to 26 days after injury. Median length of stay was 6 days (IQR 6, 9). Seven patients were discharged home in stable condition, one was discharged to an acute rehabilitation facility, and one was discharged to a skilled nursing facility.

Conclusions

Percutaneous thoracostomy with pleural lavage is clinically feasible and effective and warrants further evaluation with a multicenter clinical trial.

Level of evidence

Therapeutic/care management, level V.

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.

Predictors of initial management failure in traumatic hemothorax: A prospective multicenter cohort analysis

BACKGROUND

Traumatic hemothorax is common, and management failure leads to worse outcomes. We sought to determine predictive factors and understand the role of trauma center performance in hemothorax management failure.

METHODS

We prospectively examined initial hemothorax management (observation, pleural drainage, surgery) and failure requiring secondary intervention in 17 trauma centers. We defined hemothorax management failure requiring secondary intervention as thrombolytic administration, tube thoracostomy, image-guided drainage, or surgery after failure of the initial management strategy at the discretion of the treating trauma surgeon. Patient-level predictors of hemothorax management failure requiring secondary intervention were identified for 2 subgroups: initial observation and immediate pleural drainage. Trauma centers were divided into quartiles by hemothorax management failure requiring secondary intervention rate and hierarchical logistic regression quantified variation.

RESULTS

Of 995 hemothoraces in 967 patients, 186 (19%) developed hemothorax management failure requiring secondary intervention. The frequency of hemothorax management failure requiring secondary intervention increased from observation to pleural drainage to surgical intervention (12%, 22%, and 35%, respectively). The number of ribs fractured (odds ratio 1.12 per fracture; 95% confidence interval 1.00-1.26) and pulmonary contusion (odds ratio 2.25, 95% confidence interval 1.03-4.91) predicted hemothorax management failure requiring secondary intervention in the observation subgroup, whereas chest injury severity (odds ratio 1.58; 95% confidence interval 1.17-2.12) and initial hemothorax volume evacuated (odds ratio 1.10 per 100 mL; 95% confidence interval 1.05-1.16) predicted hemothorax management failure requiring secondary intervention after pleural drainage. After adjusting for patient characteristics in the logistic regression model for hemothorax management failure requiring secondary intervention, patients treated at high hemothorax management failure requiring secondary intervention trauma centers were 6 times more likely to undergo an intervention after initial hemothorax management failure than patients treated in low hemothorax management failure requiring secondary intervention trauma centers (odds ratio 6.18, 95% confidence interval 3.41-11.21).

CONCLUSION

Failure of initial management of traumatic hemothorax is common and highly variable across trauma centers. Assessing patient selection for a given management strategy and center-level practices represent opportunities to improve outcomes from traumatic hemothorax.

Outcomes of Pigtail Catheter Placement versus Chest Tube Placement in Adult Thoracic Trauma Patients: A Systematic Review and Meta-Analysis

INTRODUCTION

A debate currently exists regarding the efficacy of pigtail catheters vs chest tubes in the management of thoracic trauma. This meta-analysis aims to compare the outcomes of pigtail catheters vs chest tubes in adult trauma patients with thoracic injuries.

METHODS

This systematic review and meta-analysis were conducted using PRISMA guidelines and registered with PROSPERO. PubMed, Google Scholar, Embase, Ebsco, and ProQuest electronic databases were queried for studies comparing the use of pigtail catheters vs chest tubes in adult trauma patients from database inception to August 15th, 2022. The primary outcome was the failure rate of drainage tubes, defined as requiring a second tube placement or VATS, unresolved pneumothorax, hemothorax, or hemopneumothorax requiring additional intervention. Secondary outcomes were initial drainage output, ICU-LOS, and ventilator days.

RESULTS

A total of 7 studies satisfied eligibility criteria and were assessed in the meta-analysis. The pigtail group had higher initial output volumes vs the chest tube group, with a mean difference of 114.7 mL [95% CI (70.6 mL, 158.8 mL)]. Patients in the chest tube group also had a higher risk of requiring VATS vs the pigtail group, with a relative risk of 2.77 [95% CI (1.50, 5.11)].

CONCLUSIONS

In trauma patients, pigtail catheters rather than chest tubes are associated with higher initial output volume, reduced risk of VATS, and shorter tube duration. Considering the similar rates of failure, ventilator days, and ICU length-of-stay, pigtail catheters should be considered in the management of traumatic thoracic injuries.

STUDY TYPE

Systematic Review and meta-analysis.

[Occult and Retained Haemothorax - Recommendations of the Interdisciplinary Thoracic Trauma Task Group of the German Trauma Society (DGU - Section NIS) and the German Society for Thoracic Surgery (DGT)]

The management of occult and retained haemothorax is challenging for all involved in the care of polytrauma patients in terms of diagnosis and treatment. The focus of decision making is preventing sequelae such as pleural empyema and avoiding a trapped lung. An interdisciplinary task force of the German Society for Thoracic Surgery (DGT) and the German Trauma Society (DGU) on thoracic trauma offers recommendations for post-trauma care of patients with occult and/or retained haemothorax, as based on a comprehensive literature review.

[Chest Tube in Thoracic Trauma - Recommendations of the Interdisciplinary Thoracic Trauma Task Group of the German Society for Thoracic Surgery (DGT) and the German Trauma Society (DGU)]

For unstable patients with chest trauma, the chest tube is the method of choice for the treatment of a relevant pneumothorax or haemothorax. In the case of a tension pneumothorax, needle decompression with a cannula of at least 5 cm length should be performed, directly followed by the insertion of a chest tube. The evaluation of the patient should be performed primarily with a clinical examination, a chest X-ray and sonography, but the gold standard of diagnostic testing is computed tomography (CT).A small-bore chest tube (e.g. 14 French) should be used in stable patients, while unstable patients should receive a large-bore drain (24 French or larger). Insertion of chest drains has a high complication rate of between 5% and 25%, and incorrect positioning of the tube is the most common complication. However, incorrect positioning can usually only be reliably detected or ruled out with a CT scan, and chest X-rays proofed to be insufficient to answer this question. Therapy should be carried out with mild suction of approximately 20 cmH₂O, and clamping the chest tube before removal showed no beneficial effect. The removal of drains can be safely performed, either at the end of inspiration or at the end of expiration. In order to reduce the high complication rate, in the future the focus should be more on the education and training of medical staff members.

Open versus percutaneous tube thoracostomy with and without thoracic lavage for traumatic hemothorax: a novel randomized controlled simulation trial

Objective

To quantify and assess the relative performance parameters of thoracic lavage and percutaneous thoracostomy (PT) using a novel, basic science 2×2 randomized controlled simulation trial.

Summary background data

Treatment of traumatic hemothorax (HTX) with open tube thoracostomy (TT) is painful and retained HTX is common. PT is potentially less painful whereas thoracic lavage may reduce retained HTX. Yet, procedural time and the feasibility of combining PT with lavage remain undefined.

Methods

A simulated partially clotted HTX (2%-gelatin-saline mixture) was loaded into a TT trainer and then evacuated after randomization to one of four protocols: TT+/-lavage or PT+/-lavage. Standardized inserts with fixed 28-Fr TT or 14-Fr PT positioning were used to minimize tube positioning variability. Lavage consisted of two 500 mL aliquots of warm saline after initial HTX evacuation. The primary outcome was HTX volume evacuated. The secondary outcome was additional procedural time required for the addition of the lavage.

Results

A total of 40 simulated HTX trials were randomized. TT alone evacuated a median of 1236 mL (IQR 1168, 1294) leaving a residual volume of 265 mL (IQR 206, 333). PT alone resulted in a significantly greater median residual volume of 588 mL (IQR 497, 646) (p=0.002). Adding lavage resulted in similar residual volumes for TT compared with TT alone but significantly less for PT compared with PT alone (p=0.002). Lavage increased procedural time for TT by a median of 7.0 min (IQR 6.5, 8.0) vs 11.7 min (IQR 10.2, 12.0) for PT (p<0.001).

Conclusion

This simulation trial characterized HTX evacuation in a standardized fashion. Adding lavage to thoracostomy placement may improve evacuation, particularly for small-diameter tubes, with little added procedural time. Further prospective clinical study is warranted.

Level of evidence

NA.

Risk Factors for Retained Hemothorax after Trauma: A 10-Years Monocentric Experience from First Level Trauma Center in Italy

Thoracic trauma occurs in 20–25% of all trauma patients worldwide and represents the third cause of trauma-related mortality. Retained hemothorax (RH) is defined as a residual hematic pleural effusion larger than 500 mL after 72 h of treatment with a thoracic tube. The aim of this study is to investigate risk factors for the development of RH in thoracic trauma and predictors of surgery. A retrospective, observational, monocentric study was conducted in a Trauma Hub Hospital in Milan, recording thoracic trauma from January 2011 to December 2020. Pre-hospital peripheric oxygen saturation (SpO₂) was significantly lower in the RH group (94% vs. 97%, p = 0.018). Multivariable logistic regression analysis identified, as independent predictors of RH, sternum fracture (OR 7.96, 95% CI 1.16–54.79; p = 0.035), pre-admission desaturation (OR 0.96; 95% CI 0.77–0.96; p = 0.009) and the number of thoracic tube maintenance days (OR 1.22; 95% CI 1.09–1.37; p = 0.0005). The number of tubes placed and the 1° rib fracture were both significantly associated with the necessity of surgical treatment of RH (2 vs. 1, p = 0.004; 40% vs. 0%; p = 0.001). The risk of developing an RH in thoracic trauma should not be underestimated. Variables related to RH must be taken into account in order to schedule a proper follow-up after trauma.

Special Procedures for Pulmonary Disease in the Emergency Department

In the emergency department, there are infrequent but essential procedures related to pulmonary diseases that emergency physicians must be able to perform. These include thoracentesis, chest tube thoracostomy, tracheostomy manipulation, and fiberoptic intubation.

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

Introduction

Large-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.

Methods

Overall, 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.

Results

All 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).

Conclusion

After reconstruction of the chest wall and lung parenchyma, small-caliber drainage catheters could be easily and safely applied to reduce hospital LOS.