Monday 10 November 2014

Should traumatic pneumothorax get a gentle pigtail or a massive painful chest tube?

Okay, so I think you have already figured out the answer so I’ll keep this brief.

There is quite a philosophic difference in how many clinicians manage spontaneous versus traumatic pneumothorax. Spontaneous usually gets nothing or a simple aspiration whereas traumatic often are managed with chest tubes. I have been teaching ATLS (EMST) for years and the current 9th edition still advocates a massive chest tube. Why such discord?

To be honest, the following paper is rather bad but at least addresses this important issue. So please ignore the small sample size, absolutely crazy power calculation (that must have been done in retrospect), lack of blinding and confounding factors.

40 adult patients with traumatic pneumothorax were randomized to either a pigtail catheter or a 28 French chest tube. They excluded anyone with haemothorax and those who needed emergent tubes.

The primary outcome was looking at pain on a numerical rating scale (NRS) at the insertion site of either the chest tube or pigtail. Secondary outcomes included success rate and complications.

The results confirmed the obvious. Pigtails hurt a lot less. Yes, a lot less. This was statistically significant even with such a small sample size. The duration of tube insertion and success rate were all similar. Safety can never be adequately addressed with the size of this study but one would imagine it should be fine.

Will this change what we do? The quality of this evidence shouldn't change anything. But it has caused me to look at recent studies (that I must have overlooked) advocating a smaller solution to uncomplicated traumatic pneumothorax. It may not sound kosher, but I’m going the pigtail from now on.


Kulvatunyuou N, Erickson L, Vijayasekaran, A, et al. Randomized clinical trial of pigtail catheter versus chest tube in injured patients with uncomplicated traumatic pneumothorax. Br J Surg 2014;101:17-22.

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