Original Contribution

Pigtail catheters vs large-bore Chest tubes for management of secondary spontaneous pneumothoraces in adults

Wen-Kai Tsai MD^a, Wei Chen MD^b, Jen-chih Lee MD^b, Wei-Erh Cheng MD^b, Chia-Hung Chen MD^b, Wu-Huei Hsu MD^a, Chuen-Ming Shih MD, PhD^b,c,*

^aDepartments of Internal Medicine, Divisions of Chest Medicine, China Medical University Beigang Hospital,

Yulin 651, Taiwan

^bDepartments of Internal Medicine, Divisions of Pulmonary and Critical Care Medicine, China Medical university hospital,

Taichung 404, Taiwan

^cSchool of Respiratory Therapy, China Medical University, Taichung 404, Taiwan

Received 21 March 2006; revised 23 April 2006; accepted 25 April 2006

Abstract It is still uncertain if large-bore chest tubes (20F-28F) is superior to pigtail catheter (10F-14F) in terms of the management of secondary spontaneous pneumothoraces (SSP).This study was designed to compare the efficacy and safety associated with placement of large-bore chest tubes vs pigtail catheters in adults experiencing the first episode of SSP. We conducted a retrospective chart review of 91 patients experiencing the first episode of SSP in a university hospital over a 3.5-year period who received treatment by either a large-bore chest tube or a pigtail catheter. Any patient who was younger than 18 years or experiencing mechanical ventilation-related barotraumas or pyopneumothorax was excluded from this study. Various parameters including demographical characteristics, size of pneumothorax, complications, time of pigtail or chest tube extubation, and length of hospital stay were collected and analyzed. Among the enrolled 91 patients, including 76 (83.5%) men with a mean age of 60 F 19 years, 69 were initially treated with a pigtail, and 22 patients received conventional chest tubes. Fifty patients (72.5%) undergoing the Pigtail drainage and 16 (72.7%) undergoing large-bore chest tube treatment of SSP were successfully treated ( P = .88). In addition, there was no significant difference in terms of length of hospital stay, extubation time, recurrence rate, and complication. Pigtail catheters offer a safe and effective alternative for large-bore chest tubes to adult patients experiencing the first episode of SSP, and we strongly suggested that pigtail tube drainage should be considered as the initial treatment of choice.

D 2006

* Corresponding author. Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, China Medical University Hospital, Taichung 404, Taiwan. Fax: +886 4 22077618.

E-mail address: [email protected] (C.-M. Shih).

Introduction

Secondary spontaneous pneumothoraces (SSP) occur in patients with underlying lung disease such as emphysema, pulmonary tuberculosis, malignant growth, pneumonia, pulmonary fibrosis, and others, in which chronic obstructive pulmonary disease (COPD) accounts for the highest incidence [1]. Several options are available for the treatment

0735-6757/$ - see front matter D 2006 doi:10.1016/j.ajem.2006.04.006

of SSP. These include observation, oxygen supplementation, simple aspiration, tube thoracostomy, video-assisted thor- acoscopy surgery, and thoracotomy [2-4]. However, man- agement for SSP remains to be a tough problem because of the lack of widely accepted management guidelines. Guide- lines published by the British Thoracic Society recommen- ded observation alone or simple aspiration for treating minimal or asymptomatic SSP and intercostal tube drainage for large pneumothoraces initially [5]. However, Baumann

[6] suggested that simple aspiration is probably inappropri- ate for most SSP episodes because of the greater need for recurrence prevention and the potential for ongoing air leaks. In the aspect of chest tube size selection, there is no evidence to prove that the efficacies of large-bore chest tubes (20F-28F) are any better than that of small-bore pigtail catheter (10F-14F) in the management of pneumothoraces. Besides, traditional large-bore chest tubes may cause more inadvertent damage to the chest wall and the underlying organs than the smaller-bore pigtail catheters. Although many studies have confirmed that small-caliber chest tubes are just as effective as large ones, these studies, however, were primarily targeted on primary spontaneous pneumo- thoraces [7-11].

Our previous study and experience in treating primary Spontaneous pneumothorax have showed the excellent outcome of small-caliber chest tube (pigtail) drainage [12]; however, its effectiveness in management of SSP is still uncertain. In this study, we used a small-caliber chest tube (pigtail) connecting to a 1-way-valve drainage bag system in the treatment of SSP and also compared the outcome and

clinical efficacy of pigtail drainage with the standard water- sealed chest tube in the treatment of SSP.

Methods

Patients

Relevant clinical data of patients experiencing the first episode of SSP treated at China Medical University Hospital, a tertiary 1700-bed medical center in central Taiwan, from January 2002 to September 2005 were retrospectively collected and reviewed. The exclusion criteria included primary, traumatic, and iatrogenic pneumo- thoraces. Recruited patients’ chart and Chest x-ray were carefully reviewed. Only symptomatic patients with a confirmed diagnosis, an adequate follow-up CXR, and initial treatment with a chest tube or pigtail were included in the final study population. The study was conducted in accordance with the guidelines of the Declaration of Helsinki.

Pigtail tube insertion

The choice of observation, tube insertion, or surgery to treat patients with spontaneous pneumothorax was assessed and determined by clinical physicians, including thoracic surgeons, pulmonologist, and emergency physicians. Pigtail catheters (SKATER, PBN Medicals, Stenlose, Denmark) sized 10F to 14F were placed using a modified Seldinger technique (Fig. 1). In patients undergoing tube insertion, a

Fig. 1 A small-bore pigtail catheter was placed using a modified Seldinger technique. The pigtail catheter with a trocar system was inserted into the superior part of the fourth rib at the middle axillary line after a local anesthesia was injected and dilated by surgical blade, with the patient in a sitting position. The catheter was then connected to a 1-way (Heimlich) valve drainage bag.

Categorical variables are compared using v² or Fisher exact test, when appropriate (SPSS statistical software for Windows, Chicago, Ill; statistical significance, P b .05).

Table 1 Etiologic classification of secondary spontaneous

pneumothoraces enrolled in the study

Etiologic disease Patients (no. [%]) All Pigtail

patients group

Chest tube

group

COPD	46 (50)	37 (54)	9 (41)
Malignant growth	11 (12)	9 (13)	2 (9)
Pneumonia	11 (12)	6 (9)	5 (23)
Asthma	8 (8)	7 (10)	1 (5)
Pulmonary tuberculosis	7 (7)	5 (7)	2 (9)
Catamenial pneumothorax	2 (2)	2 (3)	0 (0)
Lymphangioleiomyomatosis	2 (2)	1 (1)	1 (5)
Pulmonary fibrosis	2 (2)	1 (1)	1 (5)
Pneumonoconiosis	2 (2)	1 (1)	1 (5)
Total	91 (100)	69 (100)	22 (100)

chest echo was performed first for guidance, then the pigtail catheter with a trocar system was inserted into the superior part of the fourth rib at the middle axillary line after a local anesthesia (2% lidocaine 3-5 mL) was injected and dilated by surgical blade, with the patient in a sitting position [13]. The catheter was then connected to a 1-way (Heimlich) valve drainage bag. Air, and even pleural effusion, was released from the bag when full, and the patient was closely followed up with a CXR (after 8, 24, and 48 hours). Once there was no longer air drainage from the pigtail system and the lung had reached full expansion, as revealed by CXR, the pigtail was extubated immediately. Patients were usually discharged several hours later when there were no more clinical symptoms and no air accumulated in the pleural space, as determined by close observation and follow-up CXR. Patients in the chest tube group were performed with 20F or 28F plastic tubes. The physician must make an incision into the chest wall; bluntly dissect the intercostal tissues; and place the tube into the pleural space under local anesthesia (2% lidocaine 10 mL) at the anterior MIdclavic- ular second interspace or at the fourth or fifth interspace, at the midaxillar line, and directed to the apex. The drain was connected to a 4-chamber system at water seal (0 cm H₂O) or slight aspiration (-5 cm H₂O) [14]. The timing of the follow-up CXR and the decision-making regarding extuba- tion and discharge were similar to the pigtail group.

Data collection and statistical analysis

The clinical data and information gathered for each patient included sex, age, initial symptoms, the vital sign recorded just before tube insertion, the size of the pneumothorax according to the CXR (with Light index) [15], the involved side, treatment methods, etiologic diseases, the follow-up pneumothorax size, days of hospital stay, extubation time, Recurrent episodes, complication, and reasons for changing treatment. Extubation time was calculated from the date of tube insertion.

Demographical and descriptive data are given as means

F 1 SD and compared using a 2-tailed Student t test.

Results

Initially, 143 patients with SPP were screened and then 52 patients were excluded from analysis for the following reasons: younger than 18 years (n = 7), observation only (n = 5), mechanical ventilation-associated barotraumas (n =33), incomplete follow-up (n = 2), and pyopneumo- thorax (n = 5). After screening, only 91 patients were enrolled in our series, including 76 (83.5%) men and 15 (16.5%) women. The mean age was 60 years (range, 18-91 years). Sixty-nine patients were initially treated with a pigtail, and 22 patients received conventional chest tubes.

The etiologic diseases of enrolled patients included COPD (n = 46), malignant growth (n = 11), bronchial asthma (n = 8), pulmonary tuberculosis (n = 7), pneumonia (n = 11), catamenial pneumothorax (n = 2), pulmonary fibrosis (n = 2), pneumoconiosis (n = 2), and lymphangio- leiomyomatosis (n = 2), as shown in Table 1. The incidence of COPD was the highest and accounted for 50.5%. Among the 91 enrolled patients, 70 patients currently had habit of

Table 2 Demographical characteristics of secondary sponta-

neous pneumothoraces patients treated with the chest tube or the pigtail

Data are reported as mean F SD. BMI indicates body mass index; PTX, pneumothorax; SBP, systolic blood pressure; DBP, diastolic blood pressure; PR, pulse rate; RR, respiratory rate; BT, body temperature.

Variables	Patients (no.	[%])		P
	All	Pigtail	Chest tube
	patients	group	group
Numbers Age	91 60 F 19	69 59 F 18	22 63 F 19	.77
Sex				.34
Male	76 (83.5)	56 (81.2)	20 (90.9)
Female	15 (16.5)	13 (18.8)	2 (9.1)
Height (cm)	164 F 6	164 F 6	164 F 6	.28
Body weight (kg)	54 F 10	55 F 10	52 F 10	.09
BMI	20 F 3	20 F 3	20 F 2	.17
Smoking	70 (76.9)	55 (79.7)	15 (68.2)	.17
Major Symptoms				.33
Chest pain	53 (58.2)	40 (58.0)	13 (59.1)
Dyspnea Size of PTX (%)	25 (27.5) 57 F 21	18 (26.1) 59 F 22	7 (31.8) 47 F 18	.08
Side of PTX				.42
Right	48 (53.3)	39 (56.5)	9 (42.9)
Left	42 (46.7)	30 (43.4)	12 (57.1)
Vital sign SBP (mm Hg)	126 F 30	126 F 35	125 F 34	.86
DBP (mm Hg)	75 F 13	74 F 14	77 F 14	.39
PR (per min)	94 F 22	91 F 22	101 F 23	.08
RR (per min)	22 F 3	21 F 3	23 F 4.8	.13
BT (8C)	36 F 0.6	36 F 0.6	36 F 0.7	.07

Table 3 Comparison of Treatment outcomes in secondary spontaneous pneumothorax patients treated with the pigtail catheter and the chest tube
Variables	Patient number		P
	Pigtail group	Chest tube group
Success rate	72.5% (50/69)	72.7% (16/22)	.88
Extubation (d)	9 F 4 (7)	11 F 6 (9)	.14
Hospital stay (d)	18 F 21 (11)	18 F 15 (15)	.98
6-mo recurrence rate	14 (20.3%)	3 (13.6%)	.75
Extubation time and hospital stay were expressed as mean F SD (median).

cigarette smoking. The clinical major symptoms included chest pain (n = 53 [58.2%]) and dyspnea (n = 25 [27.5%]). The other presenting symptoms included cough (n = 7) and palpitation (n = 6). Size of pneumothorax ranged from 20% to 92%, with a mean F SD of 57% F 21%, whereas 48

patients (53.3%) had a right-sided and 42 patients (46.7%) had a left-sided pneumothorax. No significant differences

were found between the 2 treatment groups with respect to the demographical characteristics shown in Table 2.

Patients undergoing the pigtail catheter drainage had a similar success rate with patients who underwent large-bore chest tube treatment (72.5% vs 72.7%, P = .88). In addition, the pigtail group had a shorter extubation time and higher Recurrence rates comparing with the chest tube group. However, none of these differences reached statistical significance, as shown in Table 3. The treatment for 6 of 22 patients receiving a large-bore chest tube treatment has failed and required a further operation, with 1 patient who died of underlying condition. Among 69 patients receiving pigtail catheter drainage, as shown in Fig. 2, 19 patients were not successfully treated, whereas 8 patients subse- quently underwent thoracoscopy with pleurodesis, 1 patient later died of complications from his underlying disease, and 10 patients underwent large-bore chest tube drainage. Of these 10 patients who further underwent large-bore chest tube drainage, 4 patients also failed to a subsequent 28F thoracostomy tube and required further operation. No major

Fig. 2 Flow diagram of the progress through the treatment allocations and outcome. VATS, video-assisted thoracoscopy surgery.

complications occurred in the both groups, but 2 patients developed subcutaneous hematoma over the puncture site in the chest tube group.

Discussion

To our knowledge, this is the first study to compare the efficacy of pigtail catheter with large-bore chest tube as the initial treatment for patients presenting the first episode of SSP. In our preliminary data, the overall success rates in patients with SSP treated with pigtail drainage was 72.5%, which was similar to that treating with large-bore chest tube drainage. In addition, there were no significant differences in terms of extubation time, length of hospital stay, and recurrence rates between the 2 groups. As a result, pigtail catheter with 1-way-valve bag drainage appears to be a safe and promising technique in the treatment of the first episode of SSP.

In the early stage of this study, our physicians or surgeons used to perform large-bore chest tube as their initial management for treating all types of pneumothoraces. However, the usage of pigtail catheter had increased gradually with the successful clinical experience in our hospital. That was the reason why the patient’s numbers in the large-bore chest tube group were smaller than that of the pigtail group.

Patients requiring mechanical ventilation were excluded from this study because of the difficulty to discriminate whether the pneumothorax was caused by underlying lung diseases or barotraumas. Further study may be required to verify this issue. Patients with pyopneumothorax were also excluded from this study because of complex pathogenesis of pleural involvement, which was largely different to the pathogenesis of pneumothorax in other SSP [16]. This study is also not applicable to pediatrics because patients younger than 18 years were excluded.

There are several recognized causes of SSP, including COPD, pneumonia, malignancy, bronchial asthma, pulmo- nary fibrosis, and pulmonary tuberculosis. The predominant etiology of SSP was various and dependent on the prevalence of these diseases in the study population. In a large-scale Japanese study of pneumothorax, tuberculosis was the most common cause of SSP in women, whereas data from United Kingdom and this study have shown the most common cause was COPD [17,18]. However, whether pigtail catheter treatment is particularly beneficial for any specific etiology of SSP is still in doubt because the sample size of various etiologies was too small to perform a statistically significant analysis.

To perform the traditional large-bore chest tube, the physician must make an incision into the chest wall, bluntly dissect the intercostal tissues, and place the tube into the pleural space. Insertion requires significant force, which may cause inadvertent damage to the chest wall and the underlying organs. The advantage of the pigtail method is

that it is easy to perform and offers simpler procedures for the physician, less trauma and discomfort for the patient, and no ambulatory limitation [19]. In addition, we perform this procedure under echocardiographic guidance to confirm the diagnosis of pneumothorax with the absence of pleural gliding sign, which was demonstrated as absence of hyperechoic pulmonary interface during respiratory motions [20], as well as to evaluate the presence of pleural effusion and locate the solid organ position.

The major limitations of this study include its retrospec- tive nature and the relatively small sample size. Therefore, it is required to conduct a large, randomized, prospective trial for further investigation.

In conclusion, our results showed that the pigtail with 1- way-valve bag drainage appears to be a safe and promising technique in the treatment of the first episode of SSP in adults. We recommend that pigtail tube drainage be considered as the initial treatment of choice in patients with the first episode of SSP in adults. However, a large randomized trial for the evaluation of the clinical application of this technique is required.

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