Chest tubes hurt…I imagine. And the few times I’ve done them (x2) I’ve wondered couldn’t that person have just gotten a pigtail?!

What does the literature say?

Voisin et al 2014 asked if large pneumothoraces (>2-3cm from the lung apex) could be evaluated as outpatients with pigtail catheters.

  • Findings
    • They looked at 132 patients with primary and secondary pneumothoraces (underlying lung disease ex: COPD) and discharged 103 with q2d evaluation managed as outpatients
    • 103 patients w/ outpt mgmt had complete resolution of pneumothorax (PTX) by Day 2 or 4
    •  7 additional patients were initially managed as outpatients and then discharged
    • The overall success rate (103 outpatients + 7 inpatients transitioned to outpatients=110) was 83%
    • potential cost savings of approx $3,000 (Euro as study was done in France) with patients managed as outpatients vs inpatients
  • Limitations
    • recurrence rate at 1 year was 26% although similar recurrence rate in literature with chest tube insertion
    • retrospective analysis
    • relatively small sample size of secondary pneumothoraces (22 patients) which are the ones we probably see the most
  • Consensus
    • Yes! we can use them to drain large amounts of air (I am)

What about fluid? Effusion? Yes but not complicated and low suspicion for loculations (but this is in flux see literature)

Hemothorax? Trauma? You may think: (1) Won’t the blood get stuck? or (2) Can we relieve air/blood in time for trauma patients?

Maybe?! But there aren’t a lot of studies on this.

  • Kulvatunyou et al group have done numerous studies on both use of pigtails in blood and trauma.
  • In 2012 Kulvatunyou et al did a prospective study looking at 36 patients who got 14Fr pigtails compared to 191 who received chest tubes (size 32-40Fr). They found similar amount of drainage in both groups, similar complication rates, tube duration, and failure. But clearly not a lot of patients in the pigtail group.
  • We need more studies!

RECAP:

  • Use pigtails for Air both primary and secondary PTXs
  • Use pigtails for Simple Effusions avoid use if high suspicion/evidence of loculations (but stay tuned!)
  • Generally do not use pigtails in trauma and hemothoraces but this consensus may be changing…!

Procedure:

Video: https://www.youtube.com/watch?v=ExAKcElqCDo

Visual Aid: http://epmonthly.com/article/pigtail-insertion/

glim

[George Lim EPmonthly] Thank you George Lim for donating your body to science, you are missed!

*Shoutout to Dr. Moira Carroll for doing a pigtail on a guy with a “YUGE!!” pneumothorax this week!!
*Also if anyone can name this cat there may be a reward in store!!!
Recent study of pigtail use in hemothorax. For those who can’t get enough swine:  Russo, R. M., Zakaluzny, S. A., Neff, L. P., Grayson, J. K., Hight, R. A., Galante, J. M., & Shatz, D. V. (2015). A pilot study of chest tube versus pigtail catheter drainage of acute hemothorax in swine. Journal of Trauma and Acute Care Surgery, 79(6), 1038-1043.

Sources:

  • Westafer, L. and Faust, J. 2016. Pneumothorax. <http://foamcast.org/2016/03/19/episode-36-pneumothorax/>
  • Westafer, L. http://www.foamem.com/?s=pigtail+catheter
  • Lin, M. 2014. ALiEM-Annals of EM Journal Club: Spontaneous pneumothorax, pigtail catheters, and outpatient management. <https://www.aliem.com/2014/aliem-annals-em-journal-club-spontaneous-pneumothorax-pigtail-catheters-outpatient-management/>
  • Kulvatunyou, N., Joseph, B., Friese, R. S., Green, D., Gries, L., O’Keeffe, T., … & Rhee, P. (2012). 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, 73(6), 1423-1427.
  • Voisin F, Sohier L, Rochas Y, Kerjouan M, Ricordel C, Belleguic C, Desrues B, Jouneau S. Ambulatory management of large spontaneous pneumothorax with pigtail catheters. Ann Emerg Med. 2014 Sep;64(3):222-8. PMID: 24439715