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.

REBEL Core Cast 34.0 – Chest Tubes

Spontaneous Pneumothorax Management

• 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

Need Aspiration

• 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

Size Matters

• 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

Hemothorax

• 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

Chest Tube Complications

• 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

Antibiotics

• 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

More on the Topic

• REBEL EM: Spontaneous Pneumothorax: Stand There and Do Nothing?
• REBEL EM: Ultrasound Detection Pneumothorax
  
• Taming the SRU: Needle Thoracostomy
  
• REBEL EM: What is the best anatomical position for needle thoracostomy
• EM Docs: Pneumothorax

Shownotes Written By: Miguel Reyes, MD (Twitter: @miguel_reyesMD)

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

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