Effectiveness and safety of small-bore chest tubes (20 Fr) for chest trauma patients

The optimal chest tube size for the relief of traumatic haemo/pneumothorax is not known. Traditionally, garden hoses up to 36 to 40 Fr in size have been recommended. The outer diameter of one of these tubes is up to 13mm… ouch!

A more recent observational study caused ATLS/EMST to recommend tubes a bit small at 28-32 Fr. This is still something I don’t think I would want hanging out of my chest.

Not based on any high-quality evidence, these authors from Kobe, Japan decided that 20 Fr or an 8 Fr pigtail was good enough. After some time, they decided to describe their results. Yes… this was their methods.

Results?

Over 5 years, they put in 107 chest tubes. About 90% were 20 Fr and the rest were pigtail catheters. The mean Injury Severity Scale (ISS) was 17.8.

There were 8 (7.8%) tube related complications, and none were due to tube obstruction. There were 4 retained haemothoraxes and 4 unresolved pneuomothoraxes.

The authors conclude that it might be reasonable to safely manage chest trauma patients with small-bore chest tubes.

This retrospective observational study is of low-quality evidence and should not change practice. But it may provide some clinical equipoise to support a proper randomized trial. This should definitively answer the research question.

After all these years, I’m quite surprised a large RCT has not been conducted. It strikes me that it should be feasible and ethical to perform. These are usually the major challenges in conducting experimental trials. A review of clinicaltrials.gov shows only one small study out of Egypt but it is not yet recruiting.

What are we waiting for? (There must be something I’m missing…Bueller... Bueller ?)

Covering:

Maezawa T, Yanai M, Young Huh J, et al. Effectiveness and safety of small-bore tube thoracostomy (<20 Fr) for chest trauma patients: A retrospective observational study. Am J Emerg Med. 2020;38:2658-2660. [link to article]