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Does that PTX Need a Chest Tube?

Drew Kalnow, DO and Andy Little, DO

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The summary below is from an episode of ERcast: Clinical Perspectives

Pneumothorax and hemothorax drainage has shifted toward smaller tubes and pigtail catheters without sacrificing effectiveness. In emergency medicine, the key decisions are who needs pleural decompression now, where to enter the chest, and when speed still favors a standard tube.

Chest Tube Choice and Placement

  • Pigtail first approach: Pigtail catheters in the 10-16 Fr range now cover most standard thoracostomy indications, with less chest wall trauma and complication burden than traditional large-bore tubes.
  • Same indications different device: Pneumothorax, hemothorax, hemopneumothorax, empyema, chylothorax, and clinically significant pleural effusions can all be managed with a pigtail when the patient and setup allow.
  • Complication tradeoff pattern: For spontaneous pneumothorax, small-bore drainage achieved similar success rates to larger tubes while large-bore devices carried more infections; dislodgement is the main pigtail downside.
  • Preferred decompression site: The 4th or 5th intercostal space at the mid-axillary line is favored over anterior 2nd-space needle decompression because procedural success is better across body habitus. We get into the landmarking nuance in the episode.
  • Trauma and unstable exceptions: Blunt or penetrating trauma resuscitation still leaves room for a standard chest tube, because speed and simplicity can matter more than the lower-trauma pigtail setup.
  • Direction and fixation pearls: During pigtail placement, aim toward the contralateral sternoclavicular joint to keep the catheter tip superior, then secure it well because dislodgement remains a recurring failure mode.

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References:

  1. Roberts JS, et al. Efficacy and complications of percutaneous pigtail catheters for thoracostomy in pediatric patients. Chest. 1998;114(4):1116-1121. PMID:9792586
  2. Adel Salah Bediwy, Hesham Galal Amer, "Pigtail Catheter Use for Draining Pleural Effusions of Various Etiologies", International Scholarly Research Notices, vol. 2012, Article ID 143295, 6 pages, 2012. https://doi.org/10.5402/2012/143295
  3. Gottlieb M, et al. Bougie-assisted tube thoracostomy placement: a novel technique. Am J Emerg Med. 2016;34(1):101-102. PMID:26527179
  4. Russo RM, et al. A pilot study of chest tube versus pigtail catheter drainage of acute hemothorax in swine. J Trauma Acute Care Surg. 2015;79(6):1038-1043. PMID:26317812
  5. Orlando A, et al. Comparing complications of small-bore chest tubes to large-bore chest tubes in the setting of delayed hemothorax: a retrospective multicenter cohort study. Scand J Trauma Resusc Emerg Med. 2020;28(1):56. Published 2020 Jun 22. PMID:32571367
  6. Benton IJ, Benfield GF. Comparison of a large and small-calibre tube drain for managing spontaneous pneumothoraces. Respir Med. 2009;103(10):1436-1440. PMID: 19502043
  7. Bauman ZM, et al. A Prospective Study of 7-Year Experience Using Percutaneous 14-French Pigtail Catheters for Traumatic Hemothorax/Hemopneumothorax at a Level-1 Trauma Center: Size Still Does Not Matter. World J Surg. 2018;42(1):107-113. PMID: 28795207

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