Many would be aware that although there has been a move to treat small and occult pneumothoraces with observation, in general a significant pneumothorax is treated by the insertion of a thoracostomy tube. However it is not altogether surprising that in an era where minimal intervention is a by-word there would be a move to treat traumatic pneumothorax in the same way.
This paper, from Peter Rhee and his group at the University of Arizona reviewed the performance of percutaneous pigtail catheters inserted via a Seldinger technique with standard chest tubes for treatment of prneumothorax over a 2 year period. Sadly, this was not a randomized controlled trial but rather a retrospective review of 2 years of experience in treating pneumothoraces at a Level 1 Trauma Centre. No information is given as to why some patients were treated with chest tubes and others with pigtail catheters but 386 patients were treated with chest tubes and 94 with pigtail catheters. Most of the pigtails (75) were inserted for simple pneumothoraces but some were inserted for haemothoraces and haemothoraces. Interestingly there were no significant differences in the demography or injury severity of the two patient groups but the pigtail group only stayed 6 days whereas the chest tube group stayed 15 and that difference was statistically significant. Complications occurred at an equal rate in the two groups.
While the science is not strong in this paper it is noteworthy that over the period of the study at the Trauma Centre the use of chest tubes dropped to about one third of the previous level. Interestingly, this paper earned an editorial comment and this noted that while the paper was observational the author of the editorial did not feel that a large randomized trial was necessary, rather just accumulation of more observational studies. It was felt ease of insertion and applicability to a wider range of healthcare environments and providers meant the technique should be increasingly used and the results reported.
What does this mean in the Australasian setting?
Undoubtedly this technique could be used successfully in a range of patients with simple pneumothorax in the context of minor trauma and the elderly may well reduce length of stay and cost. Recognising the problems that seem to accompany the insertion of chest tubes in Australia and NZ one could be attracted to this method. However it is worth noting that the complication rate wasn’t reduced with pigtail catheters in this study and the complications that did eventuate were major.
Conversely, if standard chest tube insertion became a less common technique and was practiced less often, the facility with this technique, which is already surprisingly low, might deteriorate further. For simple pneumothoraces and particularly in the elderly the pigtail catheter might be a good option. For the benefit of many patients who need positive pressure ventilation with major injuries and who have haemopneumothoraces, such as may be the case in many patients who trigger trauma calls, a standard chest tube, 28-36Fr in an adult, is probably the best option both for the patient, and to maintain the expertise of the trauma care providers.