In patients with traumatic pneumothorax, smaller really is better, a study has shown.
The prospective, randomized study found that 14-French pigtail catheters function as well as do traditional, large-bore 28-French chest tubes, and result in significantly less tube-site pain.
The average numerical rating tube-site pain score was 3.2 with the pigtail catheter vs. 7.7 with the chest tube on the day of insertion, 1.9 vs. 6.2 on day 1 (both P values less than .001), and 2.1 vs. 5.5 on day 2 (P = .04).
Chest wall pain was similar between the two groups at all three time points (6.1 vs. 6.0; 5.5 vs. 5.9; and 4.2 vs. 5.9), as was intravenous pain medication use on day 1 (mean 10.3 U vs. 15.4 U) and day 2 (5.0 U vs. 8.6 U). One unit equaled 1 mg morphine, 25 mcg fentanyl, or 0.1 mg hydromorphone HCl (Dilaudid).
It stands to reason that the pigtail catheters are less painful because they’re soft, have a coiled tip, and are inserted with a less-invasive percutaneous technique, whereas traditional, large-bore chest tubes are straight and stiff, and are typically placed via a cutdown technique, Dr. Narong Kulvatunyou said at the annual meeting of the Eastern Association for the Surgery of Trauma.
A recent prospective observational study found no difference in tube-site pain with large (36- to 40-French) versus small (28- to 32-French) chest tubes inserted for chest trauma (J. Trauma Acute Care Surg. 2012;72:422-7), but the analysis still compared two large bores and both used the cutdown technique, he observed.
Based on their early experience in trauma patients, Dr. Kulvatunyou and his colleagues at the University of Arizona, Tucson, reported that 11% of pigtail catheters failed versus 4% of chest tubes (P = .06) (J. Trauma 2011;71:1104-7).
The 2-year review did not assess tube-site pain, prompting the current prospective study involving 40 patients with traumatic pneumothorax evenly randomized to a 14F pigtail catheter placed at the bedside with a modified Seldinger technique or a 28F chest tube placed via a cutdown technique. The tubes were left on suction for 24 hours.
Patients were excluded if they required emergency pigtail or chest tube placement or were unable to respond to the nurse-led pain assessment.
Demographics in the pigtail and chest tube groups were similar in average Injury Severity Score (14.5 vs. 12.2), abbreviated chest injury score (3 vs. 3), blunt trauma injury (85% vs. 80%), rib fractures (both 1.5), and pulmonary contusion (both 25%). Patients’ mean age was 46 years; 80% were male.
Contrary to expectations, tube-site pain was similar whether the pigtail catheter was placed anteriorly between the second and third rib (n = 9) or laterally (n = 11) between the fourth and fifth rib, Dr. Kulvatunyou said.
Failure rate, defined as unresolved or recurrent pneumothorax requiring a second tube, was 5% in the pigtail group and 10% in the chest tube group (P = .55). Secondary endpoints included insertion-related complications (10% for both groups), median number of tube days (2 for both), and median hospital stay (4 days for both).
Invited discussant Dr. David King, a trauma and acute care surgeon at Massachusetts General Hospital, Boston, questioned whether patients were receiving oral pain medications, as this could impact the results, and how the team mitigated a potential Hawthorne effect and observer bias.
"I know you said that the nurses who were getting the pain scores were blinded, but it’s pretty difficult to blind someone to the difference between a garden hose and a straw coming out of their chest wall," he said.
Dr. Kulvatunyou acknowledged that 10 out of 10 patients would prefer a smaller tube if asked, but that patients were asked only whether they would be willing to receive a "different tube that works pretty well," with no mention of tube size. As for the nurses, he said the tubes were typically under dressings and that some nurses may not have noticed the difference – a remark that was not well received based on comments after the session.
Data on oral medications were not collected because they were rarely used in the first 2 days and it was difficult to compare the oral medications, but Dr. Kulvatunyou said the point was well taken.
He noted that pigtail catheters could have a role in other traumatic indications such as hemothorax, hemopneumothorax, and emergency situations, but that additional studies are needed to show that it has equal efficacy to those chest tubes.