Efficacy of chest X-rays after drain removal in adult and pediatric patients undergoing cardiac and thoracic surgery: A systematic review

Omission of Routine Chest X-Rays After Chest Tube Removal Is Safe and Feasible After Thoracic Surgery: A Single Institution Quality Improvement Initiative

INTRODUCTION

Postpull chest x-rays (CXRs) are routinely performed following chest tube (CT) removal in thoracic surgery patients even in the absence of clinical concern, but their clinical use and cost-effectiveness have been questioned.

METHODS

This is a retrospective, quality improvement study that compared clinical outcomes and cost between thoracic surgery patients who underwent routine postpull CXRs (preintervention group) versus selective CXRs (postintervention group) following CT removal.

RESULTS

A total of 569 patients were included in the analysis. The preintervention and postintervention group included 433 and 136 patients, respectively, with comparable characteristics and surgical approach. Postpull CXRs were significantly reduced (preintervention versus postintervention; 87.3% versus 5.9%, P ≤ 0.001) without a statistical difference in incidence of CXR abnormalities (33.1% versus 12.5%, P = 0.28). Clinical symptoms after CT removal were comparable between the two groups (3.7% versus 3.7%, P = 1.00). Within 2 wk, CT replacement (3.0% versus 0.7%, P = 0.21) and readmission (9.0% versus 8.1%, P = 0.71) rates were not significantly different. Fewer postintervention patients underwent routine CXR at 2-wk follow-up visit (75.3% versus 17.6%, P ≤ 0.001). The total cost per patient in the preintervention group was $783.18 whereas the postintervention group was $90.35 resulting in an 8.7-fold decrease.

CONCLUSIONS

Omission of routine CXRs after CT removal in asymptomatic thoracic surgery patients did not impact clinical outcomes while also significantly reducing cost. A selective approach to imaging based on clinical symptoms is safe and feasible.

Is It Safe to Omit Any Chest X-Ray Before Removing the Chest Drain After Elective, Non-Cardiac Thoracic Surgery? A Single-Center, Retrospective, Case-Control Study

BACKGROUND

Every patient undergoing non-cardiac thoracic surgery will receive several chest X-rays through the perioperative period. The patient might receive a preoperative X-ray as a baseline as well as several X-rays before and after drain removal. This routine has several disadvantages, for the patient, the health care system and the medical staff. Purpose of this study was to examine if all X-rays before removal of the drain can be omitted.

METHODS

Two hundred fifty-five patients who underwent elective thoracic surgery were included in this retrospective analysis. Patients undergoing urgent procedures or empyema surgery, as well as patients with symptoms requiring further diagnostic measures or patients who required clamping of the drain before removal, were excluded.

RESULTS

Forty-five patients received an X-ray before removal of the drain, and 210 patients did not. The X-ray group developed significantly more minor complications than the no X-ray group. 46.7% of the X-rays before drain removal (X-ray group) were reported with abnormalities. However, these abnormalities never led to a change in patient care. Drainage time and postoperative hospital stay were significantly longer in the X-ray group.

CONCLUSIONS

Omitting any X-ray between surgery and removal of the chest drain appears to be safe in our retrospective patient cohort. The proposed benefits of omitting the X-ray are very relevant for the health care system, the medical and nursing teams, and, more importantly, for the patients. Evidence suggests that X-ray of patients regularly do not exist. It is therefore reasonable to consider exploring this question in a formal prospective trial.

Replacing post-chest tube removal chest radiographs with clinical assessment in adult thoracic surgery patients: A single-center prospective study

Objective

The necessity and utility of chest radiographs in the absence of clinical symptoms have been questioned after chest tube removal. This study aimed to evaluate the impact of replacing routine chest radiographs after chest tube removal with clinical observation on outcomes in patients undergoing elective thoracic surgery.

Methods

This was a single-center prospective study of adult patients undergoing elective lung resection. Standard chest radiographs after chest tube removal were replaced with a clinical observation protocol for 2 hours after removal. Chest radiographs after chest tube removal were meant to be obtained only for symptomatic patients. The primary outcome was the incidence of adverse events related to this change. Secondary outcomes included changes in clinical management, length of stay, and postoperative complications.

Results

A total of 248 patients were included in the study period, and the majority (n = 185, 75%) did not have chest radiographs after chest tube removal. There was no significant difference in the incidence of adverse events or postoperative complications between patients who received chest radiographs and those who did not. Additionally, length of stay was significantly shorter in patients who did not receive chest radiographs (median 2.3 vs 3 days; P < .05).

Conclusions

Clinical observation can safely replace routine chest radiographs after chest tube removal in asymptomatic patients undergoing elective thoracic surgery. This approach may lead to shorter hospital stays and reduced healthcare costs without compromising patient safety. The findings support a clinically driven use of postoperative imaging in this patient population, highlighting the importance of individualized patient care.

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.

Decision-Making in Pleural Drainage Following Lung Resection in Children: A Western Pediatric Surgery Research Consortium Survey

INTRODUCTION

Studies of adults undergoing lung resection indicated that selective omission of pleural drains is safe and advantageous. Significant practice variation exists for pleural drainage practices for children undergoing lung resection. We surveyed pediatric surgeons in a 10-hospital research consortium to understand decision-making for placement of pleural drains following lung resection in children.

METHODS

Faculty surgeons at the 10 member institutions of the Western Pediatric Surgery Research Consortium completed questionnaires using a REDCap survey platform. Descriptive statistics and bivariate analyses were used to characterize responses regarding indications and management of pleural drains following lung resection in pediatric patients.

RESULTS

We received 96 responses from 109 surgeons (88 %). Most surgeons agreed that use of a pleural drain after lung resection contributes to post-operative pain, increases narcotic use, and prolongs hospitalization. Opinions varied around the immediate use of suction compared to water seal, and half routinely completed a water seal trial prior to drain removal. Surgeons who completed fellowship within the past 10 years left a pleural drain after wedge resection in 45 % of cases versus 78 % in those who completed fellowship more than 10 years ago (p = 0.001). The mean acceptable rate of unplanned post-operative pleural drain placement when pleural drainage was omitted at index operation was 6.3 % (±4.6 %).

CONCLUSIONS

Most pediatric surgeons use pleural drainage following lung resection, with recent fellowship graduates more often omitting it. Future studies of pleural drain omission demonstrating low rates of unplanned postoperative pleural drain placement may motivate practice changes for children undergoing lung resection.

LEVEL OF EVIDENCE

V.

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.