When size matters: changing opinion in the management of pleural space-the rise of small-bore pleural catheters

Thoracostomy tube withdrawal during latter phases of expiration or inspiration: a systematic review and meta-analysis

PURPOSE

In patients with thoracic injuries, tube thoracostomy is routinely employed. There is disagreement over which manner of tube withdrawal is best, the latter phases of expiration or inspiration. Considering several earlier investigations' inconsistent findings, their comparative effectiveness is still up for debate. In light of this, we carried out a systematic analysis of studies contrasting the withdrawal of thoracostomy tubes during the latter stages of expiration versus inspiration for traumatic chest injuries. Analyzed outcomes are recurrent pneumothoraces, reinsertion of the thoracostomy tube, and hospital stay.

METHODS

We looked for papers comparing the withdrawal of the thoracostomy tube during the last stages of expiration and inspiration for the management of thoracic injuries on Embase, Pubmed, Cochrane Library and Google Scholar. Review Manager was used to determine mean differences (MD) and risk ratios (RR) using a 95% confidence interval (CI).

RESULTS

The primary outcomes showed no significant difference between the inspiration and expiration groups: recurrent pneumothorax (RR 1.27, 95% CI 0.83-1.93, P 0.28) and thoracostomy tube reinsertion (OR: 1.84, CI 0.50-6.86, P 0.36, I2 5%). However, the duration of hospital stay was significantly lower in patients in whom the thoracostomy tube was removed at the end of inspiration (RR 1.8, 95% CI 1.49-2.11, P < 0.00001, I2 0%). The implications of these findings warrant cautious interpretation, accounting for potential confounding factors and inherent limitations that may shape their significance.

CONCLUSION

The thoracostomy tube can be removed during both the end-expiratory and end-inspiratory stages of respiration with no appreciable difference. Nevertheless, caution should be exercised when ascertaining the implications of these findings, taking into account the potential limitations and confounding variables that may exert influence upon the outcomes.

Development and content validation of the checklist for assessing placement of a small-bore chest tube (CAPS) for small-bore chest tube placement

Background

Small-bore chest tube (SBCT) placement via modified Seldinger technique is a commonly performed invasive procedure for treatment of pleural effusion and pneumothorax. When performed suboptimally, it may lead to serious complications. Validated checklists are central to teaching and assessing procedural skills and may result in improved health care quality. In this paper, we describe the development and content validation of a SBCT placement checklist.

Methods

A literature review across multiple medical databases and seminal textbooks was performed to identify all publications describing procedural steps involved in SBCT placement. No studies were identified that involved systematic development of a checklist for this purpose. After the first iteration of a comprehensive checklist (CAPS) based on literature review was developed, the modified Delphi technique involving a panel of nine multidisciplinary experts was used to modify it and establish its content validity.

Results

After four Delphi rounds, the mean expert-rated Likert score across all checklist items was 6.85 ± 0.68 (out of 7). The final, 31-item checklist had a high internal consistency (Cronbach's alpha = 0.846) with 95% of the responses (by nine experts across 31 checklist items) being a numerical score of 6 or 7.

Conclusions

This study reports the development and content validity of a comprehensive checklist for teaching and assessing SBCT placement. For purposes of demonstrating construct validity, this checklist should next be studied in the simulation and clinical setting.

Management of thoracic empyema in children: a survey of the Australia and New Zealand Association of Paediatric Surgeons (ANZAPS)

PURPOSE

To define the spectrum of management for thoracic empyema in children in Australia and New Zealand.

METHODS

Online survey of members of the Australian and New Zealand Association of Paediatric Surgeons (ANZAPS), limited to consultant/attending paediatric surgeons.

RESULTS

A total of 54/80 (67.5%) members, from 16 paediatric surgical centres, responded. The majority (33/54, 61%) preferred chest drain with fibrinolytics, whilst 21/54 (39%) preferred video-assisted thoracoscopic surgery (VATS) with drain insertion. Urokinase was the most commonly used fibrinolytic (64%). There were no significant differences in management preferences between practising surgeons in Australia and New Zealand (p = 0.54), nor between consultants who had been practising a shorter (< 5 years) or longer (> 20 years) amount of time (p = 0.21). The practices described by the surveyed ANZAPS members were in line with the Thoracic Society of Australia and New Zealand recommendations for the management of paediatric empyema.

CONCLUSION

Across Australia and New Zealand there exists significant variation surrounding the intra- and post-intervention management of thoracic empyema in children. The surveyed paediatric surgeons demonstrated a preference for fibrinolytics over the use of VATS. All management regimens were within published local guidelines.

Rapid resolution of severe subcutaneous emphysema causing respiratory failure with subcutaneous drain

This case reports on a critically ill patient (Male, 74) with severe subcutaneous emphysema which progressed to causing respiratory distress. We document both the severity of the condition we observed and then present a novel intervention. In this case, we decompressed the patient at the intensive care unit-bedside and resolved the condition. While subcutaneous emphysema is relatively common, the severity of the condition we observed, and the lack of definitive treatment guidance have prompted us to present this case as a plausible treatment guide.

Use of Medical Thoracoscopy for Retrieval of Broken Intrapleural Catheter

Small-bore pleural catheters are used to drain simple effusions effectively. They are less invasive and more comfortable than tube thoracostomy. As with any other intervention, these small catheters have their associated complications. Herein, we report a case of a young woman who was diagnosed with tuberculous pleural effusion. Easydrain pleural catheter was inserted to drain the effusion; it broke in situ because of improper insertion and was later removed using medical thoracoscopy. We emphasize on the need for proper training for doctors and staff regarding these procedures to avoid undue complications. We have also highlighted the importance of medical thoracoscopy in the removal of retained intrapleural foreign bodies.

The use of small-bore wire-guided chest drains for the management of feline pyothorax: A retrospective case series

Background:

Pyothorax in cats is routinely managed, at least initially, with thoracic tube placement associated with systemic antimicrobial administration. Traditionally, large-bore trocar-type thoracostomy tubes have preferentially been used for the drainage of thick material from the pleural space. In recent years, the use of small-bore wire-guided thoracic drains has increased in both small animals and in humans. Few studies have highlighted the efficacy of small-bore wire-guided thoracostomy tubes.

Aim:

The purpose of this study was to describe the use of small-bore wire-guided thoracostomy tubes in feline pyothorax in terms of efficacy, safety, and outcome.

Methods:

Cats with pyothorax managed with small-bore thoracostomy tubes (SBTTs) (2015–2018) were retrospectively studied. The number of drains inserted, the need for anesthesia and analgesia for chest tube placement and maintenance, and related major and minor complications were reviewed. Clinical data, diagnostic results, treatment, and outcome were recorded.

Results:

Ten cats were enrolled. Thoracostomy tube placement was unilateral in 7/10 cats, despite the presence of bilateral effusion in 9/10 cats, and required sedation (8/10) or anesthesia (2/10). Three cats experienced minor complications during the chest tube insertion, including self-limiting pneumothorax (1/3) and malpositioning (2/3). One cat had a major complication (non-functional malposition) requiring reposition of the drain. Pain management was adequately achieved using opioids (8/10) or opioids plus nonsteroidal anti-inflammatory drugs (2/10). Partial chest tube occlusion occurred in three cases and it was resolved with lavage. In one case, the occlusion was complete, requiring drain removal. Three out of 10 cats were treated medically, combining thoracostomy tubes and antibiotics, while 7/10 cats underwent surgery. All the cats survived.

Conclusion:

SBTTs represent a safe and effective option for the initial management of feline pyothorax. In fact, mainly minor complications were reported during insertion and usage. The SBTTs were well tolerated by the cats with a satisfactory performance in terms of exudate drainage in most cases. The combined use of a small-bore thoracostomy drain together with the common practice of surgical treatment might have resulted in the successful management of the cases presented.

Are Chest Radiographs Routinely Indicated After Chest Tubes Placed for Non-Surgical Reasons Are Removed?

Background

The insertion and subsequent removal of chest tubes are frequently performed procedures for the management of pneumothoraces, pleural effusions, and cardio-thoracic surgical interventions. A chest radiograph is commonly obtained after the removal of a chest tube to rule out the interval development of a pneumothorax. This practice has been questioned in various retrospective and prospective studies conducted on surgical patient populations, showing little to no benefits in performing routine chest X-rays (CXRs) after chest tube removal unless clinical symptoms such as worsening respiratory status and hemodynamic compromise are present.

Material and Methods

A four-year retrospective study was conducted using the Cleveland Clinic Foundation database. A chart review was performed, and 1,032 patients were screened, with 200 patients meeting inclusion criteria. The inclusion criteria included patients who underwent chest tube insertion for non-surgical reasons. The primary outcome was the percentage of clinically significant pneumothoraces detected by routine CXR after chest tube removal.

Results

Out of the 200 patients included in the study, 53 had a CXR after chest tube removal showing a residual pneumothorax. Out of the 53 patients, 50 ended up not needing chest tube re-insertion, as the patients were asymptomatic and hemodynamically stable. Only three patients required chest tube re-insertion due to respiratory symptoms and significant hemodynamic changes after the chest tubes were removed. In all three cases, the symptoms manifested prior to the CXRs being obtained; therefore, the decision to reinsert each chest tubes was made based on clinical signs rather than imaging. As expected, the practice of repeating CXRs after removal of the chest tubes resulted in delayed discharges despite patients reporting no symptoms and being hemodynamically stable.

Conclusions

Our study findings correlate with prior smaller studies on surgical patients. Symptoms and hemodynamic data seem to be a better predictor of whether a patient will require chest tube re-insertion or not. Routine CXR after chest tube removal also leads to prolonged hospital stay.

Chest drain and thoracotomy for chest trauma

Traumas are the leading cause of death in the first four decades of life. Nevertheless, thoracic traumas only seldom require invasive procedures. In particular, chest drain placement is required in case of pleural disruption causing haemothorax, pneumothorax or haemopneumothorax. Although large-bore chest drains have been traditionally used in case of haemothorax, recent evidences seem to question this routine, showing good performances of small-bore and pig tail drains. Although it is a common procedures, experience and training is needed to avoid complications which might be even lethal. Surgical exploration after thoracic trauma is rare, accounting for less than 3% of traumas. Penetrating traumas more likely require surgical exploration compared to blunt trauma. Anterolateral thoracotomy is usually performed in this setting, but also clamshell or hemi-clamshell approach can be used. In selected patients, minimally invasive techniques can be performed. Large randomized trials are still needed to assess and standardized the role of new tools and procedures in the thoracic trauma setting.

How spontaneous pneumothorax is managed in emergency departments: a French multicentre descriptive study

Background

Management of spontaneous pneumothorax (SP) is still subject to debate. Although encouraging results of recent studies about outpatient management with chest drains fitted with a one-way valve, no data exist concerning application of this strategy in real life conditions. We assessed how SP are managed in Emergency departments (EDs), in particular the role of outpatient management, the types of interventions and the specialty of the physicians who perform these interventions.

Methods

From June 2009 to May 2013, all cases of spontaneous primary (PSP) and spontaneous secondary pneumothorax (SSP) from EDs of 14 hospitals in France were retrospectively included. First line treatment (observation, aspiration, thoracic drainage or surgery), type of management (admitted, discharged to home directly from the ED, outpatient management) and the specialty of the physicians were collected from the medical files of the ED.

Results

Among 1868 SP included, an outpatient management strategy was chosen in 179 PSP (10%) and 38 SSP (2%), mostly when no intervention was performed. Only 25 PSP (1%) were treated by aspiration and discharged to home after ED admission. Observation was the chosen strategy for 985 patients (53%). In 883 patients with an intervention (47%), it was performed by emergency physicians in 71% of cases and thoracic drainage was the most frequent choice (670 patients, 76%).

Conclusions

Our study showed the low level of implementation of outpatient management for PS in France. Despite encouraging results of studies concerning outpatient management, chest tube drainage and hospitalization remain preponderant in the treatment of SP.

Electronic supplementary material

The online version of this article (10.1186/s12873-018-0213-2) contains supplementary material, which is available to authorized users.

Thoracic ultrasound for pleural effusion in the intensive care unit: a narrative review from diagnosis to treatment

Pleural effusion (PLEFF), mostly caused by volume overload, congestive heart failure, and pleuropulmonary infection, is a common condition in critical care patients. Thoracic ultrasound (TUS) helps clinicians not only to visualize pleural effusion, but also to distinguish between the different types. Furthermore, TUS is essential during thoracentesis and chest tube drainage as it increases safety and decreases life-threatening complications. It is crucial not only during needle or tube drainage insertion, but also to monitor the volume of the drained PLEFF. Moreover, TUS can help diagnose co-existing lung diseases, often with a higher specificity and sensitivity than chest radiography and without the need for X-ray exposure. We review data regarding the diagnosis and management of pleural effusion, paying particular attention to the impact of ultrasound. Technical data concerning thoracentesis and chest tube drainage are also provided.