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.
Covering:
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.
No comments:
Post a Comment