Pediatric Chest Tubes And Pigtails: An Evidence-Based Approach To The Management Of Pleural Space Diseases

Table of Contents

 

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Etiology And Pathophysiology
6. Differential Diagnosis
7. Prehospital Care
8. Emergency Department Evaluation
   1. History
   2. Physical Examination
9. Diagnostic Studies
   1. Chest Radiography
   2. Computed Tomography
   3. Ultrasound
10. Treatment
    1. Equipment
    2. Landmarks And Anatomy
    3. Techniques
       1. Preprocedure
       2. Needle Decompression
       3. Chest Tube Thoracostomy
       4. Pigtail Catheter Thoracostomy
       5. Postprocedure
    4. Condition-Specific Treatment
       1. Tension Pneumothorax
       2. Primary Spontaneous Pneumothorax
       3. Traumatic Pneumothorax/Hemothorax
       4. Parapneumonic Effusion And Empyema
    5. Complications
11. Special Populations
    1. Secondary Pneumothoraces
    2. Penetrating Chest Trauma
12. Controversies And Cutting Edge
    1. Primary Spontaneous Pneumothorax: Ambulatory Management
    2. Pigtail Versus Large-Caliber Tube Thoracostomy For Effusion/Empyema
    3. Ultrasound Guidance In Therapeutic Interventions In The Pleural Space
13. Disposition
14. Summary
    1. Primary Spontaneous Pneumothorax
    2. Traumatic Hemothorax/Pneumothorax
    3. Parapneumonic Effusion/Empyema
15. Risk Management Pitfalls For Management Of Pleural Space Disease In Pediatric Patients
16. Time- And Cost-Effective Strategies
17. Case Conclusions
18. Clinical Pathway For Management of Pleural Space Disease In Pediatric Patients
19. Tables and Figures
    1. Table 1. Differential Diagnosis, Air, Blood, Or Other Fluid In The Pleural Space
    2. Table 2. Relevant Historical Features When Assessing Pleural Space Disease
    3. Table 3. Relevant Physical Examination Findings When Assessing Pleural Space Disease
    4. Table 4. Calculated Pneumothorax Sizes Using The Collins Formula
    5. Table 5. Resources And Equipment Needed For Emergent Thoracostomy Procedures
    6. Table 6. Guide For Selecting Chest Tube Size
    7. Table 7. Factors Associated With Outcomes And Indication For Drainage Of Parapnuemonic Effusions
    8. Figure 1. Use Of Ultrasound To Assess For Pneumothora
    9. Figure 2. Chest Tube Insertion Landmarks
    10. Figure 3. Management Of Pneumonia With Parapneumonic Effusion
    11. Figure 4. A Theoretical Explanation Of The Lung Point
20. References

Abstract

Pediatric thoracostomy procedures are used in the emergency department to treat diseases of the pleural space. As children have unique thoracic anatomy and physiology, they may present with management challenges that the emergency clinician must consider. This issue reviews the use of chest tubes and pigtail catheters in pediatric patients, techniques and indications for placement, and possible complications. Diagnostic and treatment options for diseases of the pleural space, such as spontaneous pneumothorax, traumatic injury, and parapneumonic effusions/empyema, are examined. Additionally, this issue discusses the use of imaging modalities to aid in the diagnosis of pleural space diseases and the emerging practice of ambulatory management in certain cases.

Case Presentationss

A 4-year-old boy is brought in via EMS after a highspeed motor vehicle crash in which he was an unrestrained rear-seat passenger. His vital signs are: blood pressure, 90/59 mm Hg; heart rate, 135 beats/min; respiratory rate, 30 breaths/min; and oxygen saturation, 96% on room air. He is awake, but displays signs of altered mental status. He is maintaining his airway, has equal bilateral breath sounds, and has strong peripheral pulses. He has contusions on his face and abdomen, with an obvious right femur deformity. After 2 intravenous lines are placed, a supine chest x-ray is performed, which is read as normal. You accompany him for a head CT scan that reveals a small frontal subdural hematoma. CT scans of the neck, chest, abdomen, and pelvis are performed and reveal a left anterolateral pneumothorax. As he returns from the CT scanner, his mental status declines and he is emergently intubated to maintain his airway. Now that his airway is stabilized, you turn your attention to the pneumothorax. You remember hearing that assisted ventilation can increase the risk for tension pneumothorax physiology. Does his intubation mean that he must now have a chest tube placed?

Just as you are managing the boy who was in the motor vehicle crash, EMS notifies you that they are bringing in a 14-year-old adolescent boy who is having chest pain. He has a past medical history of cystic fibrosis and had been feeling well until he suddenly developed chest pain and difficulty breathing. His pulse oximetry reading is 94% on room air, his respiratory rate is 30 breaths/min, and his heart rate and blood pressure are normal. He has diminished breath sounds on the right side. You decide to obtain an upright chest x-ray that the radiologist reads, noting a small right-sided pneumothorax. What is the next step for this patient? Can a small pneumothorax be managed conservatively, or does his underlying lung disease require definitive treatment with a thoracostomy procedure?

Your next case is a 3-month-old girl with 1 day of respiratory distress. The mother states that the baby has been sick for 1 week with a bad cold. In the ED, the girl is in respiratory distress. You note her to be febrile, with a rapid respiratory rate and oxygen saturation of 88% on room air. Her lung exam reveals bilateral crackles with diminished breath sounds on the right and there is evidence of labored breathing. A chest x-ray reveals a moderately sized pleural fluid collection on the right. As you review this image, your thoughts are racing. Does she need a thoracostomy procedure? How can you confirm the diagnosis? Does it make a difference in her management if this is an effusion versus empyema? Should you call the surgeon to discuss the use of a video-assisted thoracostomy procedure?

Introduction

Thoracostomy procedures occur at a relatively infrequent rate in pediatric patients in the emergency department (ED). However, providing immediate interventional support for life-threatening problems of the pleural space is an essential skill for all emergency clinicians. Diseases of the pleural space include collections of air (spontaneous, traumatic, or secondary pneumothorax), fluid (effusion, chyle, or blood), or pus (empyema). Many different management strategies can be used for diseases of the pleural space, including conservative management, needle thoracostomy, catheter thoracostomy, tube thoracostomy, and video-assisted thoracoscopic surgery. The focus of this issue is on the use of chest tubes (tube thoracostomy) and pigtails (catheter thoracostomy). The existing literature was reviewed to develop a strategy for the emergency clinician that will guide in the diagnosis and management of diseases of the pleural space.

Critical Appraisal Of The Literature

A literature search was performed in PubMed using the following search terms (and their combinations): pediatrics, children, chest tubes, pigtails, thoracostomy, pneumothorax, spontaneous pneumothorax, occult pneumothorax, hemothorax, chest trauma, blunt chest trauma, pleural effusion, empyema, parapneumonic effusion, emergency medicine, re-expansion pulmonary edema, emergency ultrasound, and chest CT scan. Additionally, the bibliographies of articles were reviewed for additional relevant publications. A search of the Cochrane Database of Systematic Reviews using the search terms chest tubes and pigtails yielded 1 published article regarding simple aspiration versus intercostal tube drainage for primary spontaneous pneumothorax in adults.¹ A search of the National Guideline Clearinghouse (www.guideline.gov) using the search terms chest tubes and pigtails yielded 2 adult guidelines published by the British Thoracic Society (BTS) on pleural procedures² and management of spontaneous pneumothorax,³ and 1 pediatric guideline published by the Infectious Diseases Society of America on management of community acquired pneumonia.⁴

Many of the articles included are retrospective reviews performed primarily on adult populations. Due to the paucity of the need for procedural management of pleural disease in pediatric patients, robust prospective trials have not been performed. For this review, articles focusing on chest tube or pigtail catheter placement in the pediatric patient were primarily examined, although some studies did include simple aspiration, operative intervention, or more conservative management. Prospective studies were included when possible. Additionally, this issue discusses procedural techniques that are largely technical and, for the most part, do not have an evidence-based foundation, but are based on common practice standards. The main references for discussion on technical procedural care were found in the “Thoracostomy and Related Procedures” chapter of King and Henretig’s Textbook of Pediatric Emergency Procedures.⁵

Risk Management Pitfalls For Management Of Pleural Space Disease In Pediatric Patients

1. “The pneumothorax in the patient with asthma was small and there were no symptoms, so I discharged to home.”
   Patients with an underlying lung disease should be admitted to the hospital for any size pneumothorax, regardless of symptomatology. There is a significant risk for worsening of their condition and subsequent need for pleural interventions.
2. “The traumatic hemothorax seen on the chest x-ray was small, so I observed the patient without intervention.”
   All traumatic hemothoraces seen on chest radiography should be treated with tube thoracostomy. This will prevent further complications and respiratory/circulatory compromise. Tube thoracostomy in a patient with a hemothorax will allow for further monitoring of blood loss and help determine the need for surgical exploration.
3. “There was no pneumothorax seen on a supine chest x-ray in this symptomatic trauma patient, so I ruled out any pneumothorax.”
   Supine chest x-ray is the least sensitive of the radiographic techniques in identifying a pneumothorax. All symptomatic patients should have an evaluation with either ultrasound and/ or lateral decubitus chest radiography to more reliably rule out a pneumothorax.
4. “I used nitrous oxide as sedation in preparation for chest tube placement.”
   Nitrous oxide should not be used as sedation in a patient with a pneumothorax, as it can enter the pleural space by diffusion and has been shown to cause an increase in the size of the pneumothorax.
5. “I didn’t place a chest tube for pneumothorax evacuation prior to air transport and they had to do it in the air under difficult conditions.”
   Sudden changes in atmospheric pressure (as experienced in air transport) increase the risk of tension physiology in a noncommunicating pneumothorax. Factors such as the patient’s clinical status and symptoms, as well as the experience of the clinician must be used to determine whether chest tube placement is warranted. Transport without intervention may be considered as long as needle thoracostomy is readily available if deterioration ensues.
6. “I evacuated a large pleural effusion seen on x-ray without obtaining any additional imaging.”
   A chest CT or ultrasound is recommended prior to any intervention to identify loculations in order to help determine the correct location and number of drainage sites needed.
7. “I used suction to help evacuate a primary spontaneous pneumothorax.”
   The initial use of suction in primary spontaneous pneumothorax is not recommended due to the increased risk of re-expansion pulmonary edema. The preferred method is to attach the drainage tube to a water seal.
8. “I treated a small parapneumonic effusion with oral antibiotics alone.”
   Both the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America recommend intravenous antibiotics as the initial treatment of a small parapneumonic effusion.
9. “I treated a second episode of spontaneous pneumothorax with evacuation and discharge to home without obtaining further workup or consultation.”
   Pediatric patients are much more likely to have an underlying predisposing factor compared to adults. Conditions leading to increased risk of spontaneous pneumothorax include cystic fibrosis, pneumonia, congenital lung cyst, and Marfan syndrome.
10. “I did not consider surgical thoracotomy or blood transfusion with a large-volume output (> 20 mL/kg) of blood from a chest tube.”
    A large volume of hemorrhage from a chest tube suggests a significant injury that needs immediate life-saving action. Consideration should be given to surgical thoracotomy and/or blood transfusion. Autotransfusion is a safe alternative for blood transfusion in the appropriately selected patient, if performed correctly

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study will be included in bold type following the references, where available. The most informative references cited in this paper, as determined by the author, will be noted by an asterisk (*) next to the number of the reference.

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