Is Routine Chest Radiograph Necessary after Chest Tube Removal? Janine P. Cunningham, E. Marty Knott, Alessandra C. Gasior, David Juang, Charles L. Snyder, Shawn D. St. Peter, Daniel J. Ostlie PII: DOI: Reference:
S0022-3468(14)00012-8 doi: 10.1016/j.jpedsurg.2014.01.004 YJPSU 56634
To appear in:
Journal of Pediatric Surgery
Received date: Revised date: Accepted date:
3 December 2013 7 January 2014 11 January 2014
Please cite this article as: Cunningham Janine P., Knott E. Marty, Gasior Alessandra C., Juang David, Snyder Charles L., St. Peter Shawn D., Ostlie Daniel J., Is Routine Chest Radiograph Necessary after Chest Tube Removal?, Journal of Pediatric Surgery (2014), doi: 10.1016/j.jpedsurg.2014.01.004
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
RI P
SC
Janine P. Cunningham E. Marty Knott Alessandra C. Gasior David Juang Charles L. Snyder Shawn D. St. Peter Daniel J. Ostlie
T
Is Routine Chest Radiograph Necessary after Chest Tube Removal?
ED
MA
NU
THE CHILDREN’S MERCY HOSPITAL KANSAS CITY, MO
AC
CE
PT
Corresponding Author: Daniel J. Ostlie, MD Surgeon-in-Chief, American Family Children's Hospital Chief, Pediatric Surgery Department of Surgery University of Wisconsin 600 Highland Avenue Madison, WI 53792-7375 608-263-9419 608-261-1876 (fax) [email protected]
ACCEPTED MANUSCRIPT ABSTRACT
RI P
T
Background: Obtaining a chest radiograph (CXR) after chest tube (CT) removal to rule out a pneumothorax is a universal practice. However, the yield of this CXR has not been well documented. Additionally, most iatrogenic pneumothoraces resulting from CT removal are atmospheric in origin, asymptomatic, and can be observed. Recently, we have begun to discontinue routine CXR for CT removal. We evaluated our experience with CT removal to clarify the usefulness of routine post CT removal CXR.
NU
SC
Methods: After IRB approval, a retrospective study was conducted on patients who had a CT placed in the past decade. Cardiac patients requiring a CT were excluded. Patient demographics, diagnosis, treatments, and outcomes were collected. Patients were divided into two groups, those with a CXR after CT removal (Group 1) and those without (Group 2). Percentages were compared with Chi square with Yates correction.
ED
MA
Results: 462 patients were identified (group 1=327, group 2=135). Indications for CT included; empyema (n=176), lung resection (n=146), pneumothorax (n=71), pleural effusion (n=26), spinal fusion (n=20), trauma (n=16), and miscellaneous (n=7). Seven patients (2.1%) in group 1 required reinsertion for pneumothorax (n=4), empyema (n=2), and pleural effusion (n=1) compared to 1 patient (0.7%) in group 2 who required reinsertion for pleural effusion. This difference was not significant (P = 0.2).
CE
PT
Conclusions: In non-cardiac patients with a CT, tube reinsertion is uncommon and tube replacement is secondary to symptoms. Therefore, routine post CT removal CXR is not necessary. CXR in these patients should be obtained based upon clinical indications after CT removal.
AC
Keywords: chest tube, chest radiographs, pediatrics
ACCEPTED MANUSCRIPT Introduction Chest thoracostomy tube (CT) insertion is a common intervention or adjunct during the
T
treatment and management of trauma, primary lung disorders and pleural space disease. When
RI P
not placed for management postoperatively, a CT is nearly always placed based on patient’s signs and/or symptoms for suspected hemothorax, pneumothorax, or both [1-4]. Various
SC
algorithms exist for CT management [1, 2 , 4, 5]. Furthermore, CT removal varies significantly
NU
between institutions. Routine practice is to obtain a chest radiograph (CXR) following CT removal to evaluate for an iatrogenic pneumothorax [2, 3, 5-9]. The timing of this post removal
MA
CXR is debatable as well, with various recommendations for obtaining a CXR between 1 and 24 hours after CT removal [1, 5, 8, 10]. Controversy also exists regarding the actual need for CXR
ED
after CT removal [1, 3, 5, 6, 8, 10]. Several adult studies have reported that a CT may safely be
PT
removed without obtaining a CXR [1, 3, 6-9]. To our knowledge, there have been no reports on the significance of obtaining a CXR after CT removal in non-cardiac pediatric patients. Recently
CE
at our institution we have begun to discontinue routine CXR after CT removal. The purpose of
AC
this study was to evaluate the utility of obtaining a CXR after CT removal in non-cardiac pediatric patients. Methods
After approval from the Institutional Review Board (#11 09-142E), we conducted a retrospective review on all patients who had a CT placed at our institution from January 1, 2000 to December 31, 2010. Cardiac patients requiring a chest tube were excluded. Data collected included demographics, diagnosis, treatments, and outcomes. CXR before and after CT placement, and official radiological CXR reports were reviewed. Patients were divided into two groups. Group 1 consisted of those patients with a CXR after CT removal and Group 2 were those without a CXR
ACCEPTED MANUSCRIPT after CT removal. The decision to obtain a CXR after CT removal was dependent on surgeon preference and not on any specific disease process or other clinical determinant. Data were
T
compared with Chi-square with Yates correction.
RI P
Results
During the study period, a total of 462 patients had a CT placed (Group 1=327 patients,
SC
Group 2=135 patients). Demographic data is shown in Table 1. There were no significant
Table 1
NU
differences between groups in gender, weight, or body mass index (BMI), however patients in Group 2 were significantly older (9.4 vs. 8.0 years old, p= 0.02).
MA
Indications for CT placement are shown in Table 2. As shown in Table 3, CT reinsertion was required in 7 patients (2.1%) in Group 1
Table 2 Table 3
ED
(pneumothorax (n=4), empyema (n=2), and pleural effusion (n=1)) compared to 1 patient (0.7%)
PT
in Group 2 (pleural effusion). This difference was not significant (p=0.2). Overall, 28 patients (8.6%) in Group 1 had a radiographic report documenting a pneumothorax after CT removal.
CE
Regarding symptom development in those patients requiring CT reinsertion, 5 of 7 patients in
AC
Group 1 and the single patient in Group 2 exhibited clinical signs/symptoms after CT removal (p=0.4). The timing of post removal CXR in Group 1 was within 24 hours of CT removal in all patients.
Tables 4 and 5 detail CT reinsertion patient characteristics. Regarding specific patients, it should be noted that the patient that required CT reinsertion in Group 2 had their initial CT placed for treatment of a large pleural effusion that developed as a complication of aplastic anemia. This patient then required a CT reinsertion 16 days after the initial CT removal due to recurrent pleural effusion after patient was found on physical exam to have decrease breath sounds. Patient 1 in Group 1 also deserves specific clarification. Despite negative CXR findings after CT removal, this patient later developed low oxygen saturations that led to CT reinsertion
Table 4&5
ACCEPTED MANUSCRIPT due to documented pneumothorax on a second CXR. Patients 2 through 5 in Group 1 all had a positive CXR after removal, however CT reinsertion was based upon clinical findings.
T
There was no significant difference in length of hospital stay and length of time chest
RI P
tube was in place between groups (Table 3). Discussion
SC
Chest tube thoracostomy is the management for evacuation of air, fluid, or blood from the
NU
pleural space. Routine CXR after CT removal is standard of care in many institutions [10]. The timing of CT removal usually depends on the resolution of a hemothorax or pneumothorax, or a
MA
specified decrease in output [1]. It is known that recurrent pneumothorax or reaccumulation of fluid may occur after CT removal and it is felt that CXR performed after removal of CT offers
ED
confirmation reaccumulation has not occurred [1, 5, 7].
PT
In this study 28 patients (8.6%) from the 327 in Group 1 that underwent post CT removal CXR were found to have a pneumothorax. Of these, only 3 patients (10.7%) required CT
CE
reinsertion, and 2 of these 3 patients were clinically symptomatic. The remaining patient had a
AC
CT reinserted in a timely fashion after CXR results were reviewed. These findings are similar to previous reports in adult studies, which also documented a low incidence of iatrogenic pneumothoracies. A retrospective review of 73 patients found that 8 patients (10.9%) developed a pneumothorax after CT removal. Of these 8 patients, only 2 required CT reinsertion after clinical indications [8]. Another report found that 12 of 105 patients (11%) developed a pneumothorax after CT removal and only 1 patient, who had clinical symptoms, required CT reinsertion [1]. The authors concluded that not all pneumothorax, hemothorax, or pleural effusions are significant enough to warrant replacement of a chest tube and clinicians should monitor patients clinically. The data reported here closely mirrors the studies reported in both
ACCEPTED MANUSCRIPT percentages that had findings after CT removal and those that required reinsertion. The most common symptom precipitating CT reinsertion in our study was dyspnea that had developed due
T
to symptomatic recurrent pneumothorax.
RI P
Routine CXR results in the present study did not alter clinical management. Five patients in Group 1 and 1 patient in Group 2 developed clinical signs and/or symptoms (i.e. low oxygen
SC
saturation, dyspnea, and decreased breath sounds) that warranted further investigation that led to
NU
CT reinsertion. The 2 remaining patients in Group 1 did not develop clinical signs and/or symptoms but, rather, CT reinsertion was based on CXR results, which may or may not have
MA
been necessary. Our findings are similar to other studies which have reported that the performance of a CXR after CT removal did not assist in decision making, rather signs and
ED
symptoms combined with clinical judgement led to re-intervention [5-8]. These results suggest
PT
that it may be of benefit to reserve CXR for patients who are symptomatic after CT removal. However, the patients should be observed for a period of time to ensure that they do not develop
CE
symptoms that would prompt CT reinsertion. As all patients that required CT reinsertion in this
AC
study developed symptoms within 24 hours, we would recommend that patients be observed for 12-24 hours prior to discharge. If there is a need for discharge prior to his time, or if there are social circumstances that would place the patient at risk, the surgeon should consider obtaining a CXR prior to discharge. Although somewhat different than this study, the authors from a report regarding patients that undergo cardiac surgery and have CT removals conclude CXR should only be obtained if a patient is in respiratory distress or develops hemodynamic instability following CT removal [9].
ACCEPTED MANUSCRIPT Complications may arise after CT is discontinued including pneumothorax, bleeding, infection, and retained chest tube fragments [3, 4, 7]. In our study the only complication was the
T
need for CT reinsertion.
RI P
In the present study there was no significant difference in length of hospital stay or length of chest tube placement. This is in contrast to other reported studies that routine CXR after CT
SC
removal results in longer hospital stay. Our length of stay is likely not different because all
NU
patients that had a post removal CXR had it performed within 24 hours of removal. Of note, studies have also reported an increase in radiation exposure and hospital cost associated with
MA
post CT removal CXR [3, 5]. Conclusion
ED
In patients with a non-cardiac indicated use of CT, development of a pneumothorax after
PT
chest tube removal is rare, and routine chest radiograph to evaluate for the presence of recurrent pneumothorax after CT removal does not provide clinically relevant information. CXR should
CE
be obtained based upon clinical indications after CT removal in this population. We
AC
demonstrated that patient safety and clinical outcomes were not affected by performing a post CT removal CXR.
ACCEPTED MANUSCRIPT References
1. Pacanowski JP, Waack ML, Daley BJ, et al. Is routine roentgenography needed after closed tube thoracostomy removal? J Trauma 2000;48:684-688.
RI P
T
2. Martino K, Merrit S, Boyakye K, et al. Prospective randomized trial of thoracostomy removal algorithms. J Trauma 1999;46:369-373.
SC
3. Goodman MD, Huber NL, Johannigman JA, et al. Omission of routine chest x-ray after chest tube removal is safe in selected trauma patients. Am J Surg 2010;199:199-203.
NU
4. Adrales G, Huynh T, Broering B, et al. A thoracostomy tube guidelines improves management efficiency in trauma patients. J Trauma 2002;52:210-216.
MA
5. Boom J, Battlin M. Chest radiographs after removal of chest drains in neonates: clinical benefit or common practice? Arch Dis Child Fetal Neonatal Ed 2007;92:F46-F48. 6. Whitehouse MR, Patel A, Morgan JA. The necessity of routine post-thoracostomy tube chest radiographs in post-operative thoracic surgery patients. Surgeon 2009;2:79-81.
ED
7. Pacharan P, Heller DN, Kammen BF, et al. Are chest radiographs routinely necessary following thoracostomy tube removal? Pediatr Radiol 2002;32:138-142.
PT
8. Palesty JA, McKelvey AA, Dudrick SJ, et al. The efficacy of x-rays after chest tube removal. Am J Surg 2000;179:13-15.
CE
9. Eisenbery, RL, Khabbaz KR. Are chest radiographs routinely indicated after chest tube removal following cardiac surgery? AJR 2011;197:122-124.
AC
10. Pizano LR, Houghton DE, Cohn SM, et al. When should a chest radiograph be obtained after chest tube removal in mechanically ventilated patients? A prospective study. J Trauma 2002;53:1073-1077.
ACCEPTED MANUSCRIPT Table 1. Patient Demographics
20.0
21.0
0.6
RI P
0.06 0.02 0.06
T
P
CE
PT
ED
MA
NU
SC
Group 2 (n=135) 78:57 9.4 37.0
AC
Gender (M:F) Mean Age (yr) Mean Weight (Kg) Mean BMI
Group 1 (n=327) 158:169 8.0 32.3
ACCEPTED MANUSCRIPT Table 2. Chest tube indications
RI P
T
N 176 146 71 26 20 16 7
AC
CE
PT
ED
MA
NU
SC
Pathology Empyema Lung resection Pneumothorax Pleural effusion Spinal fusion Trauma Miscellaneous
ACCEPTED MANUSCRIPT Table 3. Outcome data P
AC
CE
PT
ED
MA
NU
SC
Mean LOS (days) 0.2 CT reinsertion 0.2 Mean CT length 0.4 (days) Clinical 5 1 0.4 signs/symptoms post CT removal LOS-length of hospital stay; CT- Chest thoracostomy tube
T
Group 2 (n=135) 11.7 (1-235) 1 4.1 (1-18)
RI P
Group 1 (n=327) 14.4 (1-170) 7 4.4 (1-35)
ACCEPTED MANUSCRIPT Table 4. Group 1 chest tube reinsertion characteristics Age (yr)
Sex
Sign
Symptom
1
16.7
M
N/A
2
13.5
F
3
15.9
F
4
16.8
F
Low saturation Low saturation Low saturation Low saturation
5
11.7
M
N/A
6
17.2
M
N/A
Dyspnea
PTX
RI P
SC
Dyspnea
NU
MA
ED
Dyspnea
Indication for CT placement Spinal fusion Empyema
T
Patient
Empyema
Dyspnea
Trauma
N/A
PTX
AC
CE
PT
7 12.2 F N/A N/A Empyema CT- chest thoracostomy tube; CXR-chest radiography; PTX-pneumothorax
CXR result
No PTX
Indication for CT reinsertion PTX
Moderate PTX PTX
PTX
No PTX, decrease pleural effusion No PTX, small pleural effusions Moderate PTX No PTX
Pleural effusion
PTX
Empyema
PTX Empyema
ACCEPTED MANUSCRIPT Table 5. Group 2 chest tube reinsertion characteristics Age (yr)
Sex
Sign
Symptom
1
16.0
M
Decreased BS
N/A
CE
PT
ED
MA
RI P
NU
SC
BS-breath sounds
AC
Indication for CT placement Pleural effusion
T
Patient
Indication for CT reinsertion Pleural effusion
S0022-3468(14)00012-8 doi: 10.1016/j.jpedsurg.2014.01.004 YJPSU 56634
To appear in:
Journal of Pediatric Surgery
Received date: Revised date: Accepted date:
3 December 2013 7 January 2014 11 January 2014
Please cite this article as: Cunningham Janine P., Knott E. Marty, Gasior Alessandra C., Juang David, Snyder Charles L., St. Peter Shawn D., Ostlie Daniel J., Is Routine Chest Radiograph Necessary after Chest Tube Removal?, Journal of Pediatric Surgery (2014), doi: 10.1016/j.jpedsurg.2014.01.004
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
RI P
SC
Janine P. Cunningham E. Marty Knott Alessandra C. Gasior David Juang Charles L. Snyder Shawn D. St. Peter Daniel J. Ostlie
T
Is Routine Chest Radiograph Necessary after Chest Tube Removal?
ED
MA
NU
THE CHILDREN’S MERCY HOSPITAL KANSAS CITY, MO
AC
CE
PT
Corresponding Author: Daniel J. Ostlie, MD Surgeon-in-Chief, American Family Children's Hospital Chief, Pediatric Surgery Department of Surgery University of Wisconsin 600 Highland Avenue Madison, WI 53792-7375 608-263-9419 608-261-1876 (fax) [email protected]
ACCEPTED MANUSCRIPT ABSTRACT
RI P
T
Background: Obtaining a chest radiograph (CXR) after chest tube (CT) removal to rule out a pneumothorax is a universal practice. However, the yield of this CXR has not been well documented. Additionally, most iatrogenic pneumothoraces resulting from CT removal are atmospheric in origin, asymptomatic, and can be observed. Recently, we have begun to discontinue routine CXR for CT removal. We evaluated our experience with CT removal to clarify the usefulness of routine post CT removal CXR.
NU
SC
Methods: After IRB approval, a retrospective study was conducted on patients who had a CT placed in the past decade. Cardiac patients requiring a CT were excluded. Patient demographics, diagnosis, treatments, and outcomes were collected. Patients were divided into two groups, those with a CXR after CT removal (Group 1) and those without (Group 2). Percentages were compared with Chi square with Yates correction.
ED
MA
Results: 462 patients were identified (group 1=327, group 2=135). Indications for CT included; empyema (n=176), lung resection (n=146), pneumothorax (n=71), pleural effusion (n=26), spinal fusion (n=20), trauma (n=16), and miscellaneous (n=7). Seven patients (2.1%) in group 1 required reinsertion for pneumothorax (n=4), empyema (n=2), and pleural effusion (n=1) compared to 1 patient (0.7%) in group 2 who required reinsertion for pleural effusion. This difference was not significant (P = 0.2).
CE
PT
Conclusions: In non-cardiac patients with a CT, tube reinsertion is uncommon and tube replacement is secondary to symptoms. Therefore, routine post CT removal CXR is not necessary. CXR in these patients should be obtained based upon clinical indications after CT removal.
AC
Keywords: chest tube, chest radiographs, pediatrics
ACCEPTED MANUSCRIPT Introduction Chest thoracostomy tube (CT) insertion is a common intervention or adjunct during the
T
treatment and management of trauma, primary lung disorders and pleural space disease. When
RI P
not placed for management postoperatively, a CT is nearly always placed based on patient’s signs and/or symptoms for suspected hemothorax, pneumothorax, or both [1-4]. Various
SC
algorithms exist for CT management [1, 2 , 4, 5]. Furthermore, CT removal varies significantly
NU
between institutions. Routine practice is to obtain a chest radiograph (CXR) following CT removal to evaluate for an iatrogenic pneumothorax [2, 3, 5-9]. The timing of this post removal
MA
CXR is debatable as well, with various recommendations for obtaining a CXR between 1 and 24 hours after CT removal [1, 5, 8, 10]. Controversy also exists regarding the actual need for CXR
ED
after CT removal [1, 3, 5, 6, 8, 10]. Several adult studies have reported that a CT may safely be
PT
removed without obtaining a CXR [1, 3, 6-9]. To our knowledge, there have been no reports on the significance of obtaining a CXR after CT removal in non-cardiac pediatric patients. Recently
CE
at our institution we have begun to discontinue routine CXR after CT removal. The purpose of
AC
this study was to evaluate the utility of obtaining a CXR after CT removal in non-cardiac pediatric patients. Methods
After approval from the Institutional Review Board (#11 09-142E), we conducted a retrospective review on all patients who had a CT placed at our institution from January 1, 2000 to December 31, 2010. Cardiac patients requiring a chest tube were excluded. Data collected included demographics, diagnosis, treatments, and outcomes. CXR before and after CT placement, and official radiological CXR reports were reviewed. Patients were divided into two groups. Group 1 consisted of those patients with a CXR after CT removal and Group 2 were those without a CXR
ACCEPTED MANUSCRIPT after CT removal. The decision to obtain a CXR after CT removal was dependent on surgeon preference and not on any specific disease process or other clinical determinant. Data were
T
compared with Chi-square with Yates correction.
RI P
Results
During the study period, a total of 462 patients had a CT placed (Group 1=327 patients,
SC
Group 2=135 patients). Demographic data is shown in Table 1. There were no significant
Table 1
NU
differences between groups in gender, weight, or body mass index (BMI), however patients in Group 2 were significantly older (9.4 vs. 8.0 years old, p= 0.02).
MA
Indications for CT placement are shown in Table 2. As shown in Table 3, CT reinsertion was required in 7 patients (2.1%) in Group 1
Table 2 Table 3
ED
(pneumothorax (n=4), empyema (n=2), and pleural effusion (n=1)) compared to 1 patient (0.7%)
PT
in Group 2 (pleural effusion). This difference was not significant (p=0.2). Overall, 28 patients (8.6%) in Group 1 had a radiographic report documenting a pneumothorax after CT removal.
CE
Regarding symptom development in those patients requiring CT reinsertion, 5 of 7 patients in
AC
Group 1 and the single patient in Group 2 exhibited clinical signs/symptoms after CT removal (p=0.4). The timing of post removal CXR in Group 1 was within 24 hours of CT removal in all patients.
Tables 4 and 5 detail CT reinsertion patient characteristics. Regarding specific patients, it should be noted that the patient that required CT reinsertion in Group 2 had their initial CT placed for treatment of a large pleural effusion that developed as a complication of aplastic anemia. This patient then required a CT reinsertion 16 days after the initial CT removal due to recurrent pleural effusion after patient was found on physical exam to have decrease breath sounds. Patient 1 in Group 1 also deserves specific clarification. Despite negative CXR findings after CT removal, this patient later developed low oxygen saturations that led to CT reinsertion
Table 4&5
ACCEPTED MANUSCRIPT due to documented pneumothorax on a second CXR. Patients 2 through 5 in Group 1 all had a positive CXR after removal, however CT reinsertion was based upon clinical findings.
T
There was no significant difference in length of hospital stay and length of time chest
RI P
tube was in place between groups (Table 3). Discussion
SC
Chest tube thoracostomy is the management for evacuation of air, fluid, or blood from the
NU
pleural space. Routine CXR after CT removal is standard of care in many institutions [10]. The timing of CT removal usually depends on the resolution of a hemothorax or pneumothorax, or a
MA
specified decrease in output [1]. It is known that recurrent pneumothorax or reaccumulation of fluid may occur after CT removal and it is felt that CXR performed after removal of CT offers
ED
confirmation reaccumulation has not occurred [1, 5, 7].
PT
In this study 28 patients (8.6%) from the 327 in Group 1 that underwent post CT removal CXR were found to have a pneumothorax. Of these, only 3 patients (10.7%) required CT
CE
reinsertion, and 2 of these 3 patients were clinically symptomatic. The remaining patient had a
AC
CT reinserted in a timely fashion after CXR results were reviewed. These findings are similar to previous reports in adult studies, which also documented a low incidence of iatrogenic pneumothoracies. A retrospective review of 73 patients found that 8 patients (10.9%) developed a pneumothorax after CT removal. Of these 8 patients, only 2 required CT reinsertion after clinical indications [8]. Another report found that 12 of 105 patients (11%) developed a pneumothorax after CT removal and only 1 patient, who had clinical symptoms, required CT reinsertion [1]. The authors concluded that not all pneumothorax, hemothorax, or pleural effusions are significant enough to warrant replacement of a chest tube and clinicians should monitor patients clinically. The data reported here closely mirrors the studies reported in both
ACCEPTED MANUSCRIPT percentages that had findings after CT removal and those that required reinsertion. The most common symptom precipitating CT reinsertion in our study was dyspnea that had developed due
T
to symptomatic recurrent pneumothorax.
RI P
Routine CXR results in the present study did not alter clinical management. Five patients in Group 1 and 1 patient in Group 2 developed clinical signs and/or symptoms (i.e. low oxygen
SC
saturation, dyspnea, and decreased breath sounds) that warranted further investigation that led to
NU
CT reinsertion. The 2 remaining patients in Group 1 did not develop clinical signs and/or symptoms but, rather, CT reinsertion was based on CXR results, which may or may not have
MA
been necessary. Our findings are similar to other studies which have reported that the performance of a CXR after CT removal did not assist in decision making, rather signs and
ED
symptoms combined with clinical judgement led to re-intervention [5-8]. These results suggest
PT
that it may be of benefit to reserve CXR for patients who are symptomatic after CT removal. However, the patients should be observed for a period of time to ensure that they do not develop
CE
symptoms that would prompt CT reinsertion. As all patients that required CT reinsertion in this
AC
study developed symptoms within 24 hours, we would recommend that patients be observed for 12-24 hours prior to discharge. If there is a need for discharge prior to his time, or if there are social circumstances that would place the patient at risk, the surgeon should consider obtaining a CXR prior to discharge. Although somewhat different than this study, the authors from a report regarding patients that undergo cardiac surgery and have CT removals conclude CXR should only be obtained if a patient is in respiratory distress or develops hemodynamic instability following CT removal [9].
ACCEPTED MANUSCRIPT Complications may arise after CT is discontinued including pneumothorax, bleeding, infection, and retained chest tube fragments [3, 4, 7]. In our study the only complication was the
T
need for CT reinsertion.
RI P
In the present study there was no significant difference in length of hospital stay or length of chest tube placement. This is in contrast to other reported studies that routine CXR after CT
SC
removal results in longer hospital stay. Our length of stay is likely not different because all
NU
patients that had a post removal CXR had it performed within 24 hours of removal. Of note, studies have also reported an increase in radiation exposure and hospital cost associated with
MA
post CT removal CXR [3, 5]. Conclusion
ED
In patients with a non-cardiac indicated use of CT, development of a pneumothorax after
PT
chest tube removal is rare, and routine chest radiograph to evaluate for the presence of recurrent pneumothorax after CT removal does not provide clinically relevant information. CXR should
CE
be obtained based upon clinical indications after CT removal in this population. We
AC
demonstrated that patient safety and clinical outcomes were not affected by performing a post CT removal CXR.
ACCEPTED MANUSCRIPT References
1. Pacanowski JP, Waack ML, Daley BJ, et al. Is routine roentgenography needed after closed tube thoracostomy removal? J Trauma 2000;48:684-688.
RI P
T
2. Martino K, Merrit S, Boyakye K, et al. Prospective randomized trial of thoracostomy removal algorithms. J Trauma 1999;46:369-373.
SC
3. Goodman MD, Huber NL, Johannigman JA, et al. Omission of routine chest x-ray after chest tube removal is safe in selected trauma patients. Am J Surg 2010;199:199-203.
NU
4. Adrales G, Huynh T, Broering B, et al. A thoracostomy tube guidelines improves management efficiency in trauma patients. J Trauma 2002;52:210-216.
MA
5. Boom J, Battlin M. Chest radiographs after removal of chest drains in neonates: clinical benefit or common practice? Arch Dis Child Fetal Neonatal Ed 2007;92:F46-F48. 6. Whitehouse MR, Patel A, Morgan JA. The necessity of routine post-thoracostomy tube chest radiographs in post-operative thoracic surgery patients. Surgeon 2009;2:79-81.
ED
7. Pacharan P, Heller DN, Kammen BF, et al. Are chest radiographs routinely necessary following thoracostomy tube removal? Pediatr Radiol 2002;32:138-142.
PT
8. Palesty JA, McKelvey AA, Dudrick SJ, et al. The efficacy of x-rays after chest tube removal. Am J Surg 2000;179:13-15.
CE
9. Eisenbery, RL, Khabbaz KR. Are chest radiographs routinely indicated after chest tube removal following cardiac surgery? AJR 2011;197:122-124.
AC
10. Pizano LR, Houghton DE, Cohn SM, et al. When should a chest radiograph be obtained after chest tube removal in mechanically ventilated patients? A prospective study. J Trauma 2002;53:1073-1077.
ACCEPTED MANUSCRIPT Table 1. Patient Demographics
20.0
21.0
0.6
RI P
0.06 0.02 0.06
T
P
CE
PT
ED
MA
NU
SC
Group 2 (n=135) 78:57 9.4 37.0
AC
Gender (M:F) Mean Age (yr) Mean Weight (Kg) Mean BMI
Group 1 (n=327) 158:169 8.0 32.3
ACCEPTED MANUSCRIPT Table 2. Chest tube indications
RI P
T
N 176 146 71 26 20 16 7
AC
CE
PT
ED
MA
NU
SC
Pathology Empyema Lung resection Pneumothorax Pleural effusion Spinal fusion Trauma Miscellaneous
ACCEPTED MANUSCRIPT Table 3. Outcome data P
AC
CE
PT
ED
MA
NU
SC
Mean LOS (days) 0.2 CT reinsertion 0.2 Mean CT length 0.4 (days) Clinical 5 1 0.4 signs/symptoms post CT removal LOS-length of hospital stay; CT- Chest thoracostomy tube
T
Group 2 (n=135) 11.7 (1-235) 1 4.1 (1-18)
RI P
Group 1 (n=327) 14.4 (1-170) 7 4.4 (1-35)
ACCEPTED MANUSCRIPT Table 4. Group 1 chest tube reinsertion characteristics Age (yr)
Sex
Sign
Symptom
1
16.7
M
N/A
2
13.5
F
3
15.9
F
4
16.8
F
Low saturation Low saturation Low saturation Low saturation
5
11.7
M
N/A
6
17.2
M
N/A
Dyspnea
PTX
RI P
SC
Dyspnea
NU
MA
ED
Dyspnea
Indication for CT placement Spinal fusion Empyema
T
Patient
Empyema
Dyspnea
Trauma
N/A
PTX
AC
CE
PT
7 12.2 F N/A N/A Empyema CT- chest thoracostomy tube; CXR-chest radiography; PTX-pneumothorax
CXR result
No PTX
Indication for CT reinsertion PTX
Moderate PTX PTX
PTX
No PTX, decrease pleural effusion No PTX, small pleural effusions Moderate PTX No PTX
Pleural effusion
PTX
Empyema
PTX Empyema
ACCEPTED MANUSCRIPT Table 5. Group 2 chest tube reinsertion characteristics Age (yr)
Sex
Sign
Symptom
1
16.0
M
Decreased BS
N/A
CE
PT
ED
MA
RI P
NU
SC
BS-breath sounds
AC
Indication for CT placement Pleural effusion
T
Patient
Indication for CT reinsertion Pleural effusion
