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Three Part Question

In [a patient with a haemothorax following trauma] is [a small bore chest drain as good as a large bore chest drain] at [achieving haemothorax resolution without complications]?

Clinical Scenario

A 27-year-old man is brought to the emergency department (ED) with a chest injury following a road traffic accident. Initial assessment reveals a right-sided haemothorax. You elect to place a chest drain and ask for the equipment to be set up. You are asked if you want a large bore 36F chest drain or a small 14F seldinger chest drain. You remember that advanced trauma life support training recommended a large bore drain but wonder if the smaller drain might be just as good and/or risk fewer complications?

Search Strategy

Medline 1950 to July 2013:
(exp wounds and injuries) AND (exp hemothorax OR hematothorax OR hematopneumothorax OR haematothorax OR haematopneumothorax OR haemothorax OR haemopneumothorax) AND (exp chest tubes OR exp thoracostomy OR “large bore” OR large OR chest drain*) AND (seldinger* OR “small bore” OR small OR “pig tail” OR pigtail OR “over wire” OR “intercostal catheter” OR icc OR “central venous catheter” OR cvc) LIMIT to: Human and English Language

EMBASE 1980 to July 2013

(exp Injury) AND (exp hematothorax OR hemothorax OR haemothorax OR hemopneumothorax OR haemopneumothorax OR haematothorax OR haematopneumothorax) AND (exp chest tube OR exp thorax drainage OR chest drain* OR “large bore” OR large) AND (seldinger* OR “small bore” OR small OR “pig tail” OR pigtail OR “over wire” OR “intercostal catheter” OR icc OR “central venous catheter” OR cvc) LIMIT to: Human and English Language

Search Outcome

49 papers of which 45 were irrelevant or of insufficient quality.
The remaining 4 papers which had some relevance to the question are summarised in the table below.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Kulvatunyou N et al 2012 USA	227 patients with traumatic haemothorax or haemopneumothorax. 14F pigtail catheters (n=36) vs 32F-40F chest tubes (n=191)	Therapeutic study, level V	Initial drainage output	No significant difference (PC 560 +/- 81 ml vs CT 426 vs 37ml)	Prospective data collection vs retrospective data for control group Small sample size Control group were younger (CT 41 +/- 1.4 vs PC 53 +/- 4 p<0.001) and had drainage earlier (CT day 0 vs PC day 1 p<0.001) PC more often inserted for blunt trauma (PC 83% vs 62% p=0.01)
			Tube duration	No significant difference
			Insertion related complications	No significant difference (PC 3 vs CT 7)
			Failure rate	No significant difference
Yi J et al 2012 China	407 patients with traumatic haemothorax randomly assigned to undergo closed pleural drainage using a central venous catheter (n=214) or a conventional chest tube (n=193)	Randomized prospective controlled study	Drainage volume throughout study	No significant difference (CVC 890 +/- 150ml vs CT 840 +/- 110ml)	Exclusion criteria extensive including patients with haemopneumothorax, patients being prescribed sedatives or anodyne, euplastic haemothorax, coagulated haemothorax, coma Unclear primary objective No blinding Randomised using odd/even dates Limited baseline characteristic comparison and lack of detailed results
			Operation time	CVC quicker (CVC 4.5 +/- 1.5min vs CT 9.4 +/- 3.0min p<0.05)
			Patients with severe complications	No significant difference (CVC 7% vs CT 7.3% p<0.05)
			Indwelling time of CVC/CT	No significant difference (CVC 4.6 +/- 2.5 days vs CT 5.0 +/- 1.7 days p>0.05)
Inaba K et al 2012 USA	293 patients requiring open chest tube drainage in a level 1 trauma centre. 353 chest tubes inserted either small (n= 186) or large (n= 167). Of these 233 patients had haemothorax and 275 chest tubes were inserted; small (n=144) and large (n=131)	Prospective observational study Level of evidence II	Initial chest tube output	No significant difference (Large 393 +/- 364ml vs small 312 +/- 314ml; p= 0.067)	No randomisation - choice of tube size down to physician Large tubes placed more often in patients with GCS <8, severe head injury, systolic BP <90mmHg, ISS <25. However both groups similar in age, gender and mechanism. Small chest tube size in this study is considered 28F to 32F whilst large is 36F or 40F. Increasingly there is interest in smaller tube sizes <20F therefore may not be directly relevant to the question.
			Duration of tube placement	No significant difference (Large 6.2 +/- 3.6 days vs Small 6.3 +/- 3.9 days; p= 0.427)
			Complications	No significant difference (Large 14.5% vs Small 16.7%; p=0.622)
			Retained haemothorax	No significant difference (Large 10.7% vs Small 11.8%; p=0.770)
			VAS pain score	Measured in 158 pts, no significant difference (Large 6.7 +/- 3.0 vs Small 6.0 +/- 3.3; p=0.237)
Rivera L et al 2008 USA	359 patients with chest injury requiring 565 tube thoracostomies. Emergent tube thoracostomies were performed in 252 patients and nonemergent in 157 which included all small catheter tube thoracostomies (107, 68%) as well as large catheter (63; 40%) not performed in the operating room or trauma room.	Retrospective case review	Complications	No significant difference (Small TT 25.2% vs nonemergent large TT 29.6%)	Retrospective study following a practice recommendation to use small catheter tube thoracostomies No randomisation - decision made by attending physician on tube size Small tubes only placed in stable patients and later after injury than nonemergent large tubes (5.5 days vs 2.3 days; p<0.001) Small tubes were placed under image guidance (CT or USS) All tubes placed by surgical staff in 1st through 4th year of residency with hands on assistance from attending trauma physician - this may not be the case in all ED\'s and may affect complication/success rates Data not separated for haemothorax/pneumothorax - may not be directly relevant to this 3 part question.

Comment(s)

The available evidence for the use of small bore catheters in traumatic haemothorax is of poor quality. There is one available randomised prospective control study but it has a poor design and unclear reporting of the results. The other three studies are observational/case reviews and using a combination of prospective and retrospective data. However, from the data that are available the results show that smaller drains appear to be as effective as larger drains in resolving traumatic haemothoraces without significant differences in terms of the amounts drained or the length of time the drain is required to remain in situ. None of the studies report an increase in complication rates compared to large bore chest drains. There are theoretical advantages to using smaller drains, including a reduction in pain experienced by the patient and possibly the speed of procedure and improved wound healing time. The use of small drains in traumatic haemothorax therefore shows promise of being at least equally as effective as large bore drains and without an increased risk of complications. However, further larger-scale prospective studies would be needed to confirm this with a higher level of evidence.

Editor Comment

CVC, central venous catheter; ED, emergency department; GCS, Glasgow coma scale; SBP, systolic blood pressure; VAS, visual analogue scale; USS, ultrasound scan.

Clinical Bottom Line

While the available evidence suggests that small bore drains may be as effective as large bore drains in resolving traumatic haemothoraces without additional complications, there is insufficient evidence currently available to recommend a change to standard practice (ie, large bore drains).

References

1. Kulvatunyou N, Joseph B, Friese RS, et al. 14 French pigtail catheters placed by surgeons to drain blood on trauma patients: Is 14-Fr too small? Journal of Trauma and Acute Care Surgery 2012;73:1423–7.
2. Yi JH, Liu HB, Zhang M, et al. Management of traumatic hemothorax by closed thoracic drainage using a central venous catheter. Journal of Zhejiang University Science B 2012;13:43–8.
3. Inaba K, Lustenberger T, Recinos G, et al. Does size matter? A prospective analysis of 28 –32 versus 36 –40 French chest tube size in trauma. Journal of Trauma 2012;72:422-427.
4. Rivera L, Rivera L, O’Reilly EB, et al. Small Catheter Tube Thoracostomy: Effective in Managing Chest Trauma in Stable Patients. The Journal of Trauma 2009;66:393-399.