LARGE OR SMALL: AN ANALYSIS OF CHEST TUBE SIZE SELECTION FOR THE MANAGEMENT OF TRAUMATIC HEMOTHORAX

Objectives: Chest tubes are the standard of care for management of traumatic hemothorax and hemopneumothorax. Previous studies have compared the efficacy of small bore pigtail catheters versus large bore chest tubes with no significant differences found in outcomes based on size. Despite these studies, few guidelines exist to help physicians select the optimal chest tube size. The objective of this study was to evaluate provider practice patterns of chest tube sizes for patients with chest trauma.

Methods: A retrospective chart review was performed on consecutive adult patients who underwent tube thoracostomy for traumatic hemothorax or hemopneumothorax at an urban Level 1 Trauma Center from January 2016 to December 2021. Comparison was made between patients who received small bore ( < 19 Fr) versus large bore (>20 Fr) thoracostomy tubes. The primary outcome was indication for chest tube placement based on injury pattern including mechanism of injury (MOI), injury severity score (ISS), and abbreviated injury scale (AIS). Secondary outcomes included retained hemothorax, insertion related complications, and duration of chest tube placement. Univariate analyses were performed.

Results: A total of 352 patients were included in the study with 86.9% of patients (n=306/352) receiving large bore chest tubes. Large bore chest tubes were more frequently placed in younger patients (37.4 +/- 15.7 vs. 49.3 +/- 18.1 years old, p< 0.0001), penetrating MOI (n=192/306, 62.7% vs n=12/46, 26.1%, p< 0.0001), and patients with higher average ISS (18.7 +/- 9.4 vs 14.7 +/- 7.9, p=0.006). Despite having a large bore chest tube, patients in this group still had a higher incidence of retained hemothorax (n=108/306, 35.3% vs n=7/46, 15.2%, p=0.01). No significant differences were found between the pigtail and chest tube groups with respect to chest tube duration, need for an additional chest tube, insertion-related complications, surgery for retained hemothorax, and hospital length of stay (p>0.05).

Conclusion: This study found a higher portion of large bore chest tubes still being placed, in particular for younger patients with penetrating trauma and more severe injuries with no significant differences found in overall hospital course and no benefit to improve the incidence of retained hemothorax. Evidence based guidelines are needed to help providers determine the optimal size chest tube to place.