Traumatic Hemothorax - Pigtail vs Chest Tube

by Dr. Ryan Kilian

uploaded by Ilyas Taraki, MS3

Some History

Hippocrates was the first physician to describe surgical treatment for pleural effusion. Approximately in the fifth century B.C. he noted:

“Then make an infusion of warm wine and oil with a tube, in order that the lung, accustomed to being soaked in pus, will not be suddenly dried out. When the pus is thin like water, sticky when touched with a finger, and small in amount, insert a hollow tin drainage tube. When the cavity is completely dried out, cut off the tube little by little, and let the ulcer unite before you remove the tube.”

Joseph-Frédéric-Benoît Charrière, medical device manufacturer whose 19th century work defined the French catheter scale.

“French” Catheter Size

The French catheter sizing scheme is based on the outer diameter of the tube.

1 French = 1/3 mm outer diameter

The larger the number, the larger the catheter (contrast with needle gauges, for which the inverse is true)

“Triangle of Safety”

Triangle formed by the borders of the pectoralis major and latissimus dorsi muscles and the 5th intercostal space (a horizontal line from the nipple).

Approximately between the anterior and mid-axillary lines.

Safe location for intercostal catheter placement.

Methods: Pigtail Catheter vs Chest Tube

Steps in pigtail catheter placement, which utilizes a smaller-bore catheter.

Chest tube placement steps. Chest tube placement requires a larger-bore catheter.

The Study

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

Authors: Narong Kulvatunyou, MD, Zachary M. Bauman, DO, Savo Bou Zein Edine, MD, Marc de Moya, MD, Casandra Krause, MD, Kaushik Mukherjee, MD, Lynn Gries, MD, Andrew L. Tang, MD, Bellal Joseph, MD, and Peter Rhee, MD

Location: University of Arizona, Tucson, Arizona; Division of Acute Care Surgery, Department of Surgery

Presentation: 51st Annual Western Trauma Association Scientific Meeting, 2/28-3/5, 2021, in Big Sky, Missouri

Journal: The Journal of Trauma and Acute Care Surgery Volume 91, Number 5

Impact Factor: 3.403 (2016)

Hypothesis

“We hypothesized that Pigtail Catheters are still equally effective as chest tubes in the management of patients with traumatic HTX.”

Methods

Undertaken between July 2015 - September 2020 at multiple institutions in Tucson, Arizona

Procedure performed by trauma attending or surgical resident

Patients randomized using random number generator to one of two treatment groups

Control: 28-32 Fr chest tube Treatment: 14 Fr Pigtail

Primary Outcome: failure rate (defined as a retained HTX requiring a second intervention)

Secondary Outcomes: daily drainage output, tube days, intensive care unit and hospital length of stay, and insertion perception experience (IPE) score on a scale of 1 to 5 (1, tolerable experience; 5, worst experience)

Funding

Cook Medical, LLC

“Family-owned medical device company that works with physicians to develop devices that are less invasive for patients.”

>12,000 Employees, $2-2.5 billion in yearly revenue

Products Used

Data

Exclusion criteria included emergency placement due to hemodynamic instability (patient was in extremis as determined by treating physician and/or unable to provide consent because of the physiologic stress produced by the trauma injuries).

Participant demographics

Demographics by site

Results table

Limitations

Goal Sample Size:  95 patients each arm with 80% power and 1-sided α of 0.05

Prolonged period of enrollment + COVID -->  interim analysis met noninferiority parameter --> concluded the study

Major Complications

Pigtail:

Chest tube:

Conclusion

“Multi-institution RCT study, we found that there was no difference in terms of the failure rate between 14-Fr PCs and large-caliber (28–32 Fr) chest tubes in their ability to drain traumatic HTX.”

“Patients [who underwent pigtail catheter placement] reported a better tube-insertion experience, meaning less pain and agony than chest tube patients.”

References

https://www.ctsnet.org/article/history-thoracic-drainage-ancient-greeks-wound-sucking-drummers-digital-monitoring

http://www.emdocs.net/unlocking-common-ed-procedures-cutting-through-the-triangle-a-review-of-tube-thoracostomy-in-the-ed/