Large- or Small-Bore Chest Tubes for Hemothorax?

November 8, 2024

Written by Aaron Lacy

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While there was concern for selection bias in a number of included studies, this systematic review and meta-analysis found that small–bore thoracostomy tubes may be appropriate to use in traumatic hemothorax.

David versus Goliath: chest tube edition
11 studies including 1,847 patients with traumatic hemothorax (81% blunt trauma) were included in this analysis. Small-bore thoracostomy tubes were pre-defined as ≤14 Fr, with large ≥20 Fr. There was no significant difference in small vs large-bore thoracostomy tube failure rate (17.8% vs 21.5%, p=0.166), complications (12.3% vs 12.5%, p=0.941), or mortality (2.9% vs 6.1%, p=0.62).

Patients who received small-bore tubes had higher initial drainage (753ml vs 398ml, p<0.001) and fewer days with a tube inside of the thoracic cavity (4.3 vs 6.2, p<0.001). Small-bore tubes had a higher rate of insertion-related complications (4.4 vs 2.2, p<0.036). 

Of the 11 trials, not all reported the outcomes of interest, and only 3 were RCTs, which may have led to bias.

How will this change my practice?
I have heard many opinions about thoracostomy tube selection. In part, this is due to a lack of high-quality data and consensus about what is best for our patients. One contributing factor is the lack of a unifying definition of what constitutes “small” and “large” bore tubes. My general practice has been to utilize catheter-based (e.g. pigtail) thoracostomy tubes in stable patients undergoing semi-elective chest tube placement and surgical chest tubes for patients who require urgent chest tubes (such as in the trauma bay). For urgent situations I generally using a 24 or 28 Fr tube, which in my mind (and in other studies) was a “small-bore” surgical chest tube, but would have been classified as “large” in this review. As an emergency physician, I work closely with or will be transferring patients to trauma and thoracic surgeons who will ultimately manage the tube. It is important to balance their viewpoint and preference with evidence and the patient experience when selecting a thoracostomy tube. I plan to discuss this article with our trauma team to work towards a team consensus for our particular system moving forward.

Source
Small versus large-bore thoracostomy for traumatic hemothorax: A systematic review and meta-analysis. J Trauma Acute Care Surg. 2024 Oct 1;97(4):631-638. doi: 10.1097/TA.0000000000004412. Epub 2024 Aug 30. PMID: 39213292.