The Knife or the Needle
Case
A 73 year-old male presents to the emergency department complaining of chest pain following an assault. The patient is alert and greets you when you enter the room to evaluate him. He has bilateral breath sounds, but you question if the right lung field sounds diminished as compared to the left. He has a strong radial pulse with a normal rate and a blood pressure of 123/84. He is oriented to person, place, and time. He lifts his gown to draw your attention to his left chest wall, where he reports being struck by an unknown assailant’s fists. His oxygen saturation is 98% on room air. He endorses a slight feeling of dyspnea, but says “it’s just because it hurts, doc.” He explains that it was a brief assault and he didn’t sustain any blows to his head.
He denies past medical history. His appendix was removed when he was a child. He takes no medications. He has no known allergies. A chest x-ray is performed:
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Diagnosis
Right sided pneumothorax.
You make the decision to place a chest tube. As you prepare to consent the patient, a colleague suggests placing a pigtail thoracostomy.
Discussion
The treatment of traumatic pneumothorax has traditionally been placement of a large-bore chest tube (conventionally 36 to 40 Fr). In the setting of spontaneous and iatrogenic pneumothorax, pigtail thoracostomy catheters have begun to gain favor as a modality. The effectiveness of placing a pigtail thoracostomy instead of a large-bore chest tube for traumatic pneumothorax in the acute setting has not been rigorously studied. Current studies cite papers from the 1990s and 2000s, though these hail from interventional radiology literature.
One is a case series comprising three patients that describes placement of pigtails for complex pneumothoraces and effusions in ventilated patients (not as an acute treatment modality). Another is a retrospective review of pigtails that were placed for traumatic pneumothorax, hemothorax, effusions, and empyema under ultrasound or CT guidance in the interventional radiology suite (again, not as an acute treatment modality). This study was not powered to demonstrate a statistically significant comparison of pigtail thoracostomy versus large-bore chest tubes in the setting of traumatic pneumothorax. A more recent retrospective study by Bauman examined the use of pigtail catheters versus large-bore chest tubes for traumatic pneumothorax, but did not reach statistical significance with comparisons of number of tube days, insertion-related complications, and number of ICU days. A subsequent randomized clinical trial by Kulvatunyou examined pain differences between pigtails and large-bore chest tubes, finding a statistically significant difference favoring pigtail thoracostomy, but otherwise it was not powered to compare efficacy.
Currently, practice guidelines for major trauma associations, including the American Association for the Surgery of Trauma and Eastern Association for the Surgery of Trauma, do not endorse the use of pigtail thoracostomy for traumatic pneumothorax. Large-bore chest tube continues to be the recommendation of the 10th edition of Advanced Trauma Life Support, however, prospective data supports the use of smaller, 28 to 32 french chest tubes, for traumatic hemothorax. For the time being, there is not a strong foundation of literature to support the use of pigtail thoracostomy in the setting of traumatic pneumothorax and further studies are needed to demonstrate their effectiveness, although the literature is trending toward the use of less invasive treatment methods.
Faculty Reviewer: Dr. Adam Aluisio
References
Available at: http://bulletin.facs.org/2018/06/atls-10th-edition-offers-new-insights-into-managing-trauma-patients/#Chapter_4_Thoracic_Trauma. Accessed September 29, 2019.
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