Traumatic Hemothorax - Pigtail vs Chest Tube
by Dr. Ryan Kilian
uploaded by Ilyas Taraki, MS3
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 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)
“We hypothesized that Pigtail Catheters are still equally effective as chest tubes in the management of patients with traumatic HTX.”
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)
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
Multipurpose Pigtail Drainage Catheter Needle Set
Turner Pigtail Pneumothorax Set
Cook Emergency Pneumothorax Set
Wayne Pneumothorax Catheter Set and Tray
Thal-Quick Chest Tube Set and Tray
Thal-Quick Double Lumen Chest Tube Set
Pneumothorax Set and Tray
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).
Demographics by site
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
“bleeding from PC necessitated a thoracotomy, but the patient did well”
one death from major PE on day 10
“extra-pleural position from chest tube placement required another tube placement”
one death from a non-trauma-related cause of death at an outside institution
“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.”