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Three Part Question

In [a patient requiring a chest drain after trauma] is [a seldinger 'over-the-wire' technique better than other methods or chest drain placement] at [achieving pneumothorax resolution without complication]?

Clinical Scenario

A 30 year old man presents to the emergency department after a road traffic accident. On initial assessment you identify a haemothorax/pneumothorax on the left side of his chest; there are no signs of tension. You elect to place a chest drain and discover that you have a seldinger 'over-the-wire' technique chest drain in front of you. You wonder whether this method of placement is be better than any other at achieving succesful management of the injury without complication.

Search Strategy

Medline 1966-12/02 using the OVID interface.
[(exp chest tubes OR exp thoracostomy OR "chest drain$".mp) AND ("seldinger".mp OR "needle wire dilator".mp OR "over wire".mp OR "small bore".mp OR pigtail.mp OR "pig tail".mp)]) LIMIT to human AND English.

Search Outcome

Altogether 28 papers were found by the Medline search. No papers were directly relevant but 3 papers had some relevance to our clinical question. These are listed in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Ahmed MY et al, 1995, USA	24 children aged 4 mths to 24yrs from a single pediatric ICU Drains inserted with deep sedation using size 10 to 20F drains	Retrospective single centre case series	Time for insertion	4 to 7 minutes	No control group Retrospective Different scenario to the emergency department
			Complications	5 tubes became kinked, causing 4 pneumothoraces to recur. 2 drains had to be reinserted. Otherwise no major complications
Patz ER Jr et al, 1998, USA	106 patients having elective insertion of a small-bore catheter for sclerotherapy for malignant pleural effusion. 14F small bore catheter was inserted by seldinger technique, with image guidance	Prospective case series	Success of insertion	No insertion failures reported	Sub-study of a sclerotherapy trial Not directly relevant to our clinical question Outcome measures were not defined prior to study
			Infections	No infections reported
			Other complications	Pain scores for insertion not done but stated that technique was well tolerated
Roberts JS et al, 1998, USA	133 chest catheters inserted into 91 children in ICU. Age range 0-18yrs. Weight 1.8-66kg 7 to 8.5F percutaneous pigtail catheters inserted in conjunction with wire and dilator by seldinger technique	Retrospective case series	Pneumothorax resolution	15 of 20 patients who had drain for pneumothorax had complete resolution (75%)	80% had congenital heart disease 67% intubated Not directly relevant to the emergency department Retrospective uncontrolled methodology
			Complications	Haemothorax (2%) Pneumothorax (2%) Empyema (1%) Cannulation of hepatic vein (1 pt) Failure to drain pneumothorax (11%) Dislogement (5%) 1/3rd of complications were in infants <5kg

Comment(s)

There is no comparative work looking at the use of a seldinger technique for placement of chest drains in adult trauma patients. Of the papers that were found uncontrolled series reports document their comparatively safe use in adults and children in well controlled elective and intensive care settings. Complications such as recurrence of the pneumothorax, kinking of the drain do still occur as is seen in the open technique, but insertion complications or difficulties seem to be rare.

Clinical Bottom Line

There is no evidence to show that a seldinger over the wire insertion technique is superior to traditional methods.

References

1. Ahmed MY, Silver P, Nimkoff L, et al. The needle-wire-dilator technique for the insertion of chest tubes in pediatric patients. Pediatr Emerg Care 1995;11(4):252-4.
2. Patz EF Jr., McAdams HP, Erasmus JJ, et al. Sclerotherapy for malignant pleural effusions: a prospective randomized trial of bleomycin vs doxycycline with small-bore catheter drainage. Chest 1998;113(5):1305-11.
3. Roberts JS, Bratton SL, Brogan TV. Efficacy and complications of percutaneous pigtail catheters for thoracostomy in pediatric patients. Chest 1998;114(4):1116-21.