Chest tube vs pig tail catheter

[The Knife & Gun Club]

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.

Anterior chest tubes for Pnx are phenomenal and a game changer. Can do it with the pt sitting straight up and way easier to position than doing the arm over head if the patient isn’t particularly compliant.

We’re still mostly doing 28s for hemothorax.

TPA/Dornase is also phenomenal for clearing out all the gunk in loculated empyemas after trauma. One of our guys calls it a YATS (Yanhour Assisted Thoractotomy) - 11 blade, finger to break up the loculations/adhesions, suction out all the crap, then put in a Chest tube and follow it with TPA/Dornase in a day or two to keep it draining.

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[Tipsy McStagger]

What interesting timing. Brand new article form the Journal of Trauma and Acute Care surgery. Small bore chest tubes <14 Fr likely as as effective for traumatic hemothorax as larger bore chest tubes.

- Retrospective chart review, so take that into consideration
- no difference in failure rate between large / small bore tubes
- No mortality difference
- No complication difference
- Small bore tubes with higher initial output and with fewer days.

Higher initial output is counterintuitive to me, but fewer days is not. Again, small bore tubes cause far less problems down the line. Large bore tubes can and do cause significant pain in many patients in the long term.

I suspect it will take years for our surgeons to buy in.

Small versus large-bore thoracostomy for traumatic... : Journal of Trauma and Acute Care Surgery

ge-bore tube thoracostomy (LBTT) (≥20F) for the treatment of HTX. METHODS Pubmed, EMBASE, Scopus, and Cochrane review were searched from inception to November 2022 for randomized controlled trials or cohort studies that included adult trauma patients with HTX who received a tube thoracostomy...

journals.lww.com

PMID: 39213292
DOI: 10.1097/TA.0000000000004412


Also…

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

Therapeutic, level II.

pubmed.ncbi.nlm.nih.gov

 

[The Knife & Gun Club]

What interesting timing. Brand new article form the Journal of Trauma and Acute Care surgery. Small bore chest tubes <14 Fr likely as as effective for traumatic hemothorax as larger bore chest tubes.

- Retrospective chart review, so take that into consideration
- no difference in failure rate between large / small bore tubes
- No mortality difference
- No complication difference
- Small bore tubes with higher initial output and with fewer days.

Higher initial output is counterintuitive to me, but fewer days is not. Again, small bore tubes cause far less problems down the line. Large bore tubes can and do cause significant pain in many patients in the long term.

I suspect it will take years for our surgeons to buy in.

Small versus large-bore thoracostomy for traumatic... : Journal of Trauma and Acute Care Surgery

ge-bore tube thoracostomy (LBTT) (≥20F) for the treatment of HTX. METHODS Pubmed, EMBASE, Scopus, and Cochrane review were searched from inception to November 2022 for randomized controlled trials or cohort studies that included adult trauma patients with HTX who received a tube thoracostomy...

journals.lww.com

PMID: 39213292
DOI: 10.1097/TA.0000000000004412


Also…

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

Therapeutic, level II.

pubmed.ncbi.nlm.nih.gov

Plus the scarring and potential neuropathy issues are not insignificant. I never really thought about it when working downstairs but we don’t change chest tubes out, so once you’ve committed to the big tube they have that tube for a while.

Putting a chest tube back in through a scarred down chest wall sucks.