Chest tube vs pig tail catheter

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Angry Birds

Angry Birds

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Can I just do a pig tail for everything?
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Yes for spontaneous pnuemothorax. No for significant traumatic hemothorax.

Maybe not the question you were asking, but can't for everything unfortunately.
 
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Mount Asclepius said:
Yes for spontaneous pnuemothorax. No for significant traumatic hemothorax.

Maybe not the question you were asking, but can't for everything unfortunately.
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There's research to support small bore/pigtail catheters for hemothorax as well. We do not place large bore catheters in all of our hemothoraces. In the resuscitation bay in a crash situation, yes. After CT in patients that are stable or semi-stable, they usually get a pigtail catheter.

rebelem.com

Traumatic Hemothorax: Pigtail vs Chest Tube - REBEL EM - Emergency Medicine Blog

Is a 14 Fr pigtail catheter noninferior to a 28–32 Fr chest tube for managing traumatic hemothorax in hemodynamically stable patients?
rebelem.com rebelem.com
 
Mount Asclepius said:
Yes for spontaneous pnuemothorax. No for significant traumatic hemothorax.

Maybe not the question you were asking, but can't for everything unfortunately.
Click to expand...
southerndoc said:
There's research to support small bore/pigtail catheters for hemothorax as well. We do not place large bore catheters in all of our hemothoraces. In the resuscitation bay in a crash situation, yes. After CT in patients that are stable or semi-stable, they usually get a pigtail catheter.

rebelem.com

Traumatic Hemothorax: Pigtail vs Chest Tube - REBEL EM - Emergency Medicine Blog

Is a 14 Fr pigtail catheter noninferior to a 28–32 Fr chest tube for managing traumatic hemothorax in hemodynamically stable patients?
rebelem.com rebelem.com
Click to expand...
See bolded.

I appreciate trying to use data to inform CT usage, but this study was underpowered with selection bias. Hard to draw any conclusions and yet they tried to do so.

I don’t think you are going to get out of placing a thoracostomy tube with a moderate to large volume hemothorax, especially if hemodynamic instability (I know study excluded, but also subjectively).
 
Hell, most PTX pts don’t even need a chest tube anymore, let alone a pigtail.
 
RustedFox said:
Can I just place a large bore chest tube for everything?
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So much more fun.

My trauma surgeons think pig tails are trash so I happily do medium bore tubes for them. Anything traumatic I drop a low 20s like 20-22g, whatever is stocked.

The only time I’ve done > 28s are for massive effusions or empyemas causing resp distress.
 
Mount Asclepius said:
See bolded.

I appreciate trying to use data to inform CT usage, but this study was underpowered with selection bias. Hard to draw any conclusions and yet they tried to do so.

I don’t think you are going to get out of placing a thoracostomy tube with a moderate to large volume hemothorax, especially if hemodynamic instability (I know study excluded, but also subjectively).
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We still use them for large volume hemothoraces (level I trauma center).
 
Indications for any chest tube placement in an emergent situation are vanishing rapidly.

Nearly all my spontaneous pneumothoraces go without.

Last actual chest tube was for penetrating trauma. If you're not at a hospital with suitable trauma volume, you just won't hardly have any reason to place them.
 
I never really understood the big chest tube is better argument. If a kid needs a chest tube for a hemothorax, they're getting something that would be considered small for an adult yet the blood drains adequately fast enough.

If I'm conscious and in the situation of needing a chest tube, you're getting a big F-You and legit threat of litigation if you propose putting in a large bore chest tube for just about any reason.
 
I can’t remember the last large bore chest tube I placed. It’s a pig tail catheter or nothing these days unless it’s some kind of trauma.
 
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Tiger26 said:
I never really understood the big chest tube is better argument. If a kid needs a chest tube for a hemothorax, they're getting something that would be considered small for an adult yet the blood drains adequately fast enough.

If I'm conscious and in the situation of needing a chest tube, you're getting a big F-You and legit threat of litigation if you propose putting in a large bore chest tube for just about any reason.
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My comment was more satirical than anything else; I'm with you on this one. The correct size is: "the one that's big enough".
 
In my mind it's less about what I am evacuating than it is about how fast it's being added. Air, blood, even pus all drain just fine most of the time through a pig tail. But if the thing is being added too fast for the pigtail to cope, then it would need a large surgical chest tube. I can only think of two scenarios:

1) large volume bronchpleural defect on positive pressure ventilation (would still probably start with a pigtail, but have rarely had to place either a second one or upgrade to a larger bore chest tube)

2) rapidly accumulating traumatic hemothorax (there I kinda want to know fast if we have a thoracotomy indication)
 
Thank you all for your feedback. Based on the fact I only ever want to reinforce my own starting opinion, I will now only do pig-tail catheters and ignore all the other opinions about this.

On a serious note, I’ve seen plenty of comments here saying we now rarely need to intervene with PTX. Can someone update me here? Last I learned, all but small PTX needs a chest tube or pig tail.
 
Angry Birds said:
Thank you all for your feedback. Based on the fact I only ever want to reinforce my own starting opinion, I will now only do pig-tail catheters and ignore all the other opinions about this.

On a serious note, I’ve seen plenty of comments here saying we now rarely need to intervene with PTX. Can someone update me here? Last I learned, all but small PTX needs a chest tube or pig tail.
Click to expand...
 
Angry Birds said:
Thank you all for your feedback. Based on the fact I only ever want to reinforce my own starting opinion, I will now only do pig-tail catheters and ignore all the other opinions about this.

On a serious note, I’ve seen plenty of comments here saying we now rarely need to intervene with PTX. Can someone update me here? Last I learned, all but small PTX needs a chest tube or pig tail.
Click to expand...

This seems like something in the category of "emerging evidence"
but if you ever consult a CT surgeon or pulmonologist, they are always going to want a tube.
It takes a long time for this kind of messaging ("we no longer need a chest tube for any spontaneous pneumo") to make it's way to every community foot solder ER / pulm / CT surgeon doc.

So you discharge them without one, and the moment they see any doctor ever, and they have a pneumo "GO BACK TO THE ER IT"S A EMERGENCY!!!"
 
It's just so hard to implement new research.

For all you community ER docs, just imaging this.

you get a guy with COPD coming in with SOB. They are not NIPPV SICK.
You get the obligatory chest xray that you expect to be negative.
"mild apical pneumo. No consolidation."

You cringe becasue you know nothing needs to be done. So you try to admit the patient for albuterol and steroids.
EVERY SINGLE community doc will say "you have to consult surgery or put a chest tube in."
They won't rely on your expertise. Or your judgement. They will all say "What happens if pneumo BLOW UP and the pt arrests! I don't put in chest tubes."

EVERY SINGLE ONE. Most community docs are just ****ies.
 
thegenius said:
It's just so hard to implement new research.

For all you community ER docs, just imaging this.

you get a guy with COPD coming in with SOB. They are not NIPPV SICK.
You get the obligatory chest xray that you expect to be negative.
"mild apical pneumo. No consolidation."

You cringe becasue you know nothing needs to be done. So you try to admit the patient for albuterol and steroids.
EVERY SINGLE community doc will say "you have to consult surgery or put a chest tube in."
They won't rely on your expertise. Or your judgement. They will all say "What happens if pneumo BLOW UP and the pt arrests! I don't put in chest tubes."

EVERY SINGLE ONE. Most community docs are just ****ies.
Click to expand...
Are you talking about the hospitalist saying you have to consult surgery or put a chest tube in? In my experience, they'd admit and consult pulm who will just watch it and continue to treat the COPD exacerbation. Not every community hospital will have pulm but I'd bet a majority do unless you are incredibly rural.
 
thegenius said:
It's just so hard to implement new research.

For all you community ER docs, just imaging this.

you get a guy with COPD coming in with SOB. They are not NIPPV SICK.
You get the obligatory chest xray that you expect to be negative.
"mild apical pneumo. No consolidation."

You cringe becasue you know nothing needs to be done. So you try to admit the patient for albuterol and steroids.
EVERY SINGLE community doc will say "you have to consult surgery or put a chest tube in."
They won't rely on your expertise. Or your judgement. They will all say "What happens if pneumo BLOW UP and the pt arrests! I don't put in chest tubes."

EVERY SINGLE ONE. Most community docs are just ****ies.
Click to expand...
Yeah so this is the issue. I can only admit a patient with a chest tube at the big place. At all the small places, it seems the only people still able to take care of chest tubes are... emergency physicians. Even at one of the small places, they asked me to pull a chest tube "because the surgeon isn't coming in today and he says it's ready to come out." This was years ago...I know better now than to be a "team player" just because someone doesn't want to do their job.

Anyway at the big house, I think I could admit the apical ptx patient without much trouble but would probably be forced to wake up the appropriate consult service so they could agree with my plan to do the right thing for the patient.
 
thegenius said:
EVERY SINGLE community doc will say "you have to consult surgery or put a chest tube in."
They won't rely on your expertise. Or your judgement. They will all say "What happens if pneumo BLOW UP and the pt arrests! I don't put in chest tubes."

EVERY SINGLE ONE. Most community docs are just ****ies.
Click to expand...
IDK man, I think your shops aren't generalizable. I admit patients with very small pneumos to medicine with a plan to do nothing except give O2 and repeat a CXR later. We don't have thoracics or anyone in house besides the ED for that matter that does chest tubes. Medicine generally trusts us that these are nothing to worry about.
 
Can’t put in a pigtail if there’s not a good landing zone which is a limitation
 
wareagle726 said:
I assume he's talking about those rather robust patients with biscuit poisoning. Tough to put a needle through 8 inches of fat. I could be completely wrong though. Wouldn't be the first time today.
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Biscuit poisoning? LOL

Our kids have a longer needle for the obese. I swear it looks so long that you could do a pericardiocentesis with it.
 
southerndoc said:
Biscuit poisoning? LOL

Our kids have a longer needle for the obese. I swear it looks so long that you could do a pericardiocentesis with it.
Click to expand...
I posted this in the past. When I worked in SC, had a pt I had to tap, that was, what's the word? Corpulent? Had rads do it. Rads called me back, saying they used "the harpoon", and had to hub the needle to get the fluid.

This is the future of America.
 
BoardingDoc said:
If there isn't an area of fluid or air big enough to safely get into with a pigtail, why are you even considering a chest tube of any kind?
Click to expand...
PTX draining into the subcutaneous space, loculated PTX or HTX sometimes.

In general I’ve seen and caused bleeding with pigtails. Intercostal arteries are not perfectly where the textbooks say. Never caused bleeding with a surgical drain. I think a lot of these studies are underpowered to make conclusions about complications that are rare but severe.

Or I’m just biased
 
wareagle726 said:
I assume he's talking about those rather robust patients with biscuit poisoning. Tough to put a needle through 8 inches of fat. I could be completely wrong though. Wouldn't be the first time today.
Click to expand...
For pigtails, I just trochar it in. No issues... people have been harpooning whales for centuries.
 
Apollyon said:
I posted this in the past. When I worked in SC, had a pt I had to tap, that was, what's the word? Corpulent? Had rads do it. Rads called me back, saying they used "the harpoon", and had to hub the needle to get the fluid.

This is the future of America.
Click to expand...

The future is here my friend.
 
Siggy said:
For pigtails, I just trochar it in. No issues... people have been harpooning whales for centuries.
Click to expand...
I was doing a left sided pigtail a year or so ago. Big fat guy. I'm nearly hubbing the finder needle before I can grab a wire when the needle suddenly starts filling rather rapidly with fairly bright appearing blood.

I immediately stare at the monitor for VT or something assuming I've just stabbed him in the heart.

He was thankfully fine, and it turns out I only hit some SQ vessel, but holy s*** that scared the hell out of me.

Anyone with biscuit poisoning who needs a chest tube now definitely gets it under US (or gets a thoracostomy tube if they're proper trauma).
 
Siggy said:
For pigtails, I just trochar it in. No issues... people have been harpooning whales for centuries.
Click to expand...
These make me nervous. I wouldn't put one in unless that lung is way down since I'm worried I'm going to go through the parenchyma or something else important. I can't comprehend why more kits aren't the Seldinger kind where you at least have the feedback of aspirating air or blood before feeding the much less scary wire.
 
thegenius said:
I remember someone here posted that chest tube trocars are associated with markedly worse outcomes.
Click to expand...

I could see chest tubes with trochars (my hospital stocks the Seldinger style for a proper large bore chest tube) being significantly different than a pig tail... which is more like an oversized and longer thoracentesis catheter (8 fr for BD Thora-Para kits vs 8.5 fr for the pigtail).
 
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Druggernaut said:
These make me nervous. I wouldn't put one in unless that lung is way down since I'm worried I'm going to go through the parenchyma or something else important. I can't comprehend why more kits aren't the Seldinger kind where you at least have the feedback of aspirating air or blood before feeding the much less scary wire.
Click to expand...
99% of the time I'm placing a pig tail, the lung is pretty far down and the second I feel any release I'm pulling the cutting needle out of the trochar and connecting the syringe to the trochar.
 
BoardingDoc said:
IDK man, I think your shops aren't generalizable. I admit patients with very small pneumos to medicine with a plan to do nothing except give O2 and repeat a CXR later. We don't have thoracics or anyone in house besides the ED for that matter that does chest tubes. Medicine generally trusts us that these are nothing to worry about.
Click to expand...

part time hospitalist here

this has been my experience since residency over a decade ago. even moderate ptx some of the cavalier pulm guys will keep on o2 for a few days and reeval

i've only placed a couple chest tubes in residency. is there a large technical difference between inserting a pigtail vs a chest tube?
 
FWIW, I use a large bore needle with lidocaine and alternate injecting and aspirating until I get a few bubbles, then stop, remove my syringe, and feed my guide wire. Pretty straightforward after that.
 
The trocar is a hollow rapier. You know who else uses a trocar liberally? Funeral directors.

My last job had these in a drawer. They were like angiocaths, in that the trocar was inside the chest tube, and protruded about 8mm out the end. Anyone who used them pulled the trocar out, and struggled to put it into the sharps container.
 
Tiger26 said:
FWIW, I use a large bore needle with lidocaine and alternate injecting and aspirating until I get a few bubbles, then stop, remove my syringe, and feed my guide wire. Pretty straightforward after that.
Click to expand...

This is the way.
Keep it simple.
 
end stage fibro said:
part time hospitalist here

this has been my experience since residency over a decade ago. even moderate ptx some of the cavalier pulm guys will keep on o2 for a few days and reeval

i've only placed a couple chest tubes in residency. is there a large technical difference between inserting a pigtail vs a chest tube?
Click to expand...
I mean, both go into the chest, but they're rather different.
Pigtail: Needle into chest until air. Wire. Trocar loaded pigtail over wire. Trocar comes out as pigtail goes in so that you don't spear them in the lung/heart.
Chest tube: Knife. Incision over rib. Kelly or similar to pop through pleura. Finger in to ensure you're right spot. Tube goes in.
 
I'm embarrassed to say it but I don't think I've ever placed a chest tube over wire or a traditional pigtail catheter outside of residency. Either most EDs I worked never had them stocked or I just didn't know about it. Maybe once that I don't remember? I've done lots of pneumodarts which is over catheter and the rest are all just old school thoracostomy tubes of varying sizes depending on what's going on. I vastly prefer traditional chest tubes due to familiarity and because I can do a quick finger thoracostomy sweep and make sure I'm in the right place and then it's easy to just pop it in and secure it. I've got a pretty obese pt population and over the years have noticed that the pneumodarts have a tendency to migrate out within the first 24 hours. If the pneumo is under 30%, I generally don't place one. So many times once you punch into the chest, the pt's languish for days with failure after failure of chest tube clamping only to result in CT consult 5 days later for VATS pleurodesis. We don't have CT surgery at my current community shop so I usually just make sure pulm is on board and admit to medicine. If I place a tube, it's a roll of the dice whether they will get transferred for VATS pleurodesis in a few days so I hate to dump the patient down that road unless I absolutely have to do it.
 
My practice in various ICUs is basically:

Pneumothorax: 8 Fr anterior pigtail. These cause fewer problems in follow up. If you’ve ever seen someone who had a large bore chest tube with neuralgia for life, you feel really badly for them. They cause a lot of pain once it’s all said and done. The 8 Fr is tiny and unless you have a bad bronchopleura fistula they’ll work fine. I doubt they’d work laterally in patients with biscuit poisoning, but anteriorly they are great. If you do have a BPF then you have other problems, but I will usually start with a 14 Fr and also place it anteriorly. Also, if you’re not placing anterior drains you should start. They’re easier, more comfortable and work amazingly well for ptx.

Hemothorax: most of my hemothoraces are post op cardiac surgery patients. I would place a 14 fr but the surgeons are creatures of habit and they usually ask me to place a 28 Fr or preferably 32 Fr. I push back but in the end it’s technically their patient so I just do the larger bore drain.

Empyema get 14 Fr pigtail so I can push tpa/dnase over the next few days since thoracic surgery never want to VATS them.

I never use the trochar.
 
At the end of the day I would prefer to do a regular thoracostomy tube with the standard 11 blade incision, Kelley, finger swipe(like Groove said). Probably just because I've done a lot more of those and can "feel" it much better. That being said the pigtails are pretty smooth. Especially for a R sided PTX lol.
 
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