REBEL Core Cast 34.0 – Chest Tubes

Take Home Points

Small to Moderate Size Pneumothorax – consider managing conservatively with observation (need to make sure consulting services on same page)
Needle aspiration for spontaneous pneumothorax recommend by British Thoracic and European Respiratory Societies
1 in 5 patients requiring a chest tube will suffer complications – many are iatrogenic in nature. Practice procedure via simulation
Chest tubes placed for traumatic pneumothoraces should get prophylactic antibiotics
When deciding on treatment strategy, discuss with your consultants and make sure you have institutional buy-in.

Traditional teaching was to put a small-bore chest tube and admit the patient
NEJM study offers evidence for conservative management and observation: Conservative versus Interventional Treatment for Spontaneous Pneumothorax
Randomized trial
Patients were randomized to either observation or invention with small bore (<12 french) chest tube
- Repeat CXR done at 1 hour
- Re-expansion of lung and no air leak, tube was clamped and repeat CXR at 4 hours
- No Recurrent of PTX, chest tube pulled and patient discharged
- Patient reassessed between 24-72 hours and had follow up visits with repeat car at 2, 4 and 8 weeks
Authors found that patients with primary spontaneous pneumothorax observation was not inferior to intervention
Observation group did take nearly twice as long to achieve radiographic resolution (16d v 30d) – non-patient centered outcome
Symptom resolution similar and observation group had less adverse events.
- Less recurrence, less days hospitalized, less days of missed work, less procedures and less hospital revisits

Typically performed at 2nd Intercostal space in the midclavicular line. However please review the last core cast about why needle decompression in this area is not ideal.
Instead, perform this procedure at the 4th or 5th intercostal space in anterior axillary line
- Easier to identify, less critical structures and thinner area
Perform using US guidance – check landmarks to be sure going into the right area
- Use 8cm 14 gauge angiocath and attach to 3 way stop cock, attach to either 50cc syringe or cavity drainage tray.
No robust literature on needle aspiration
- 2017 Cochrane review found that tube thoracostomy outperformed need aspiration in immediate success rate
  - No difference in early failure rate, one-year success rate and hospitalization rate
  - Needle aspiration associated with less adverse events

Simple pneumo with just air in pleural space – no blood / pus / effusion than 14 french pigtail catheter is appropriate
American College of Chest Physicians (ACCP) recommends stable patients with pneumothorax get small bore and the unstable patient gets a small to moderate-sized chest tube.
ACCP tube classifications
- Small-bore 7-14 french
- Moderate 16-22 french
- Large >24 french

More viscous fluid like blood or pus requires a larger tube for appropriate drainage.
Rate of drainage is directly proportional to diameter of the tube
ATLS recommends 28-32 french chest tube for traumatic hemo-pneumo thorax

Early complications
- Iatrogenic – insertional complication if tube placed into adjacent structure.
  - Lung most common structure damaged
- Positional – tube within cavity but the position is not optimal
  - Difficult to adjust – one sterile field is broken chest tube cannot be advanced
Late Complications
- Chest tube removal leading to reaccumulation of pneumothorax
- Infection – cellulitis, empyema and pneumonia
- Malfunction – persistent air leak because of bronchopulmonary fistula
- Obstruction – occlusion with blood or pus

Primary spontaneous pneumothorax – no good evidence for routine use of antibiotic prophylaxis
Chest tube s/p chest trauma – recommendation for antibiotics.
- Meta-analysis showed antibiotics reduced the risk of empyema and pneumonia

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