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?
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.
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
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.
Jonathan Strutt, MD; Anupam Kharabanda, MD, MSc
November 2, 2015
December 1, 2018
Upon completion of this article, you should be able to:
Physician CME Information
Date of Original Release: November 2, 2015. Date of most recent review: October 15, 2015. Termination date: November 2, 2018.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the Essential Areas and Policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
ACEP Accreditation: Pediatric Emergency Medicine Practice is also approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
AAP Accreditation: This continuing medical education activity has been reviewed by the American Academy of Pediatrics and is acceptable for a maximum of 48 AAP credits per year. These credits can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Fellows of the American Academy of Pediatrics.
AOA Accreditation: Pediatric Emergency Medicine Practice is eligible for up to 48 American Osteopathic Association Category 2-A or 2-B credit hours per year.
Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical ED presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
Discussion of Investigational Information: As part of the newsletter, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.
Faculty Disclosure: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr. Strutt, Dr. Kharbanda, Dr. Mitzman, Dr. Rose, Dr. Vella, Dr. Wang, and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation.
Commercial Support: This issue of Pediatric Emergency Medicine Practice did not receive any commercial support.
Earning Credit: Two Convenient Methods: (1) Go online to www.ebmedicine.net/CME and click on the title of this article. (2) Mail or fax the CME Answer And Evaluation Form with your June and December issues to EB Medicine.
Hardware/Software Requirements: You will need a Macintosh or PC with internet capabilities to access the website.
Additional Policies: For additional policies, including our statement of conflict of interest, source of funding, statement of informed consent, and statement of human and animal rights, visit https://www.ebmedicine.net/policies.