Small Percutaneous vs. Large Chest Tubes

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Swami gives us an awesome review of a study on small percutaneous tube vs. chest tube for traumatic hemothorax from EMA March 2022. 

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Ian L. -

What is the way of local anaesthesia - the ml and dose of lignocaine and how nester your infiltrate ?

Josh M. -

Good morning, great episode. We work in a small two bed ED in Eastern Washington. Our trauma cases always require air transport. Would that impact the choice between pig-tail vs. large bore tube?

@skobner -

Hey Josh! Not Swami, but hopefully I can give my 2 cents. From a physiologic standpoint, the pig-tail versus large-bore tube shouldn't matter (as the study suggests). Additionally, the barometric changes in flight should also have no significant differences in function in these devices. The only thing I might consider: what is your transport time, resources in flight, and specific logistic situation for this patient? If I had an obese, intubated trauma patient, with a significant hemopnuemo, long transport time, and limited ability to troubleshoot in-flight, I might consider placing a traditional chest tube. Having your pig-tail kink or get dislodged or (less likely) clog in this situation would require some advanced troubleshooting or possible conversion to a surgical thoracostomy to decompress the chest. I have seen this a handful of times (out of hundreds of chest tubes) at the Level I trauma center which I work. I don't personal know of data on pig-tail versus large-bore chest tube kink/dislodgment rates, and I bet 99% of this can be avoided with proper technique. This is not a very likely scenario, nevertheless it is just something I would consider if you have concerns during extensive transport.

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