Implementing a chest tube removal protocol in patients with thoracic trauma: a prospective clinical study

Introduction

Chest trauma is the second most frequent type of accidental injury, which could be blunt or penetrating (1,2). Chest trauma is responsible for 25% of the mortality; possibly higher rates may occur in patients with polytrauma (3,4). Many patients with chest trauma can quickly be stabilized and resuscitated through crucial interventions, such as needle decompression, chest decompression, and chest tube insertion (5).

Thoracostomy tube (TT), or chest tube, is a commonly used and well-established procedure for treating pneumothorax, hemothorax, or both that may develop after trauma causing respiratory compromise (6). Therefore, inserting a chest tube can help in restoring proper pulmonary ventilation. Extensive literature has described the indications, contraindications, techniques, management, and complications associated with the placement of a TT (6-8). However, the management and timing of chest tube removal can vary depending on the physician’s experience level, training, and clinical judgment (9). Different approaches exist to remove a chest tube after treating pneumothorax. Some physicians remove the chest tube if a chest radiograph shows that the lung remains fully expanded without suction. However, others prefer to clamp the chest tube for 4–6 hours and ensure the pneumothorax does not recur before removing the tube (10).

Additionally, some clinicians opt to remove suction from the chest tube for 24 hours and then use a chest X-ray (CXR) to determine whether the tube can be removed safely or not. Removing a TT as soon as it is deemed safe is advisable to reduce the chances of infection, pain, and prolonged hospitalization. However, the timing of chest tube removal in patients on a ventilator is a matter of significant importance and is subject to controversy (10). This study aimed to determine whether early removal of TT, following a standardized protocol in terms of timing and criteria, is safe and associated with better outcomes in a level 1 trauma center. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1229/rc).

Methods

This is a prospective observational study to evaluate the standardized protocol for early TT removal in patients with chest trauma admitted to a level I trauma center at Hamad General Hospital, Qatar. Collected data included patients’ demographics, body mass index (BMI) and Abbreviated Injury Scale (AIS), pattern and severity of injury, clinical and imaging findings, time of TT insertion and removal, TT size [French (Fr) units], location and output, and post-removal complications. We hypothesized that early removal of TT is feasible and safe.

Inclusion criteria

All consecutive patients admitted with chest trauma who sustained blunt or penetrating injuries were included. Both genders aged 14–90 years requiring chest tube insertion (any size and type) for treating hemothorax, pneumothorax, or hemopneumothorax. Patients with multiple chest tubes were also included.

Exclusion criteria

Thoracic trauma patients without a chest drain and TT inserted in another hospital and transferred to the Hamad Trauma Center (HTC) were excluded from the study.

Potential subjects were recruited for the study between October 2020 and April 2022 after obtaining consent from the patient or their next of kin. Once the subject was recruited, a protocol for assessing TT removal was initiated 48 hours post-TT insertion.

TT removal protocol

The protocol for TT removal included clinical and radiological criteria, as shown in Figure 1. According to the protocol, no visible air leak (or bubbling) should be observed while the TT is still under negative suction (– 20 cmH₂O). The last 24 h fluid output (serous or serosanguineous) should be less than 200 mL (based on the physiological production of the pleural fluid (0.15 mL/kg/h) (11,12). CXR is done after insertion and 2 days later (the day of assessment for removal). CXR should show a fully expanded lung and clear costophrenic or cardio-phrenic angles. If all these criteria were met, the TT was removed.

Figure 1 The study protocol: clinical and radiological criteria. CD, cardio-diaphragmatic angle; CP, cardio-phrenic angle; CXR, chest X-ray; SS, serosanguinous; TT, thoracotomy tube.

The TT was usually removed by a trauma fellow/specialist or a trauma resident (under the direct supervision of the trauma fellow or specialist). TT removal was done while still on negative pressure applied after insertion, without ‘off-suction’ day(s) or clamping before removal. The non-intubated patients were instructed to hold breathing at full inspiration and performed a Valsalva maneuver (13). For intubated patients, TT removal was performed at the end of the inspiratory phase of the breathing cycle of the ventilator. The removal was achieved by removing the transfixing sutures first and then pulling the tube rapidly. At the same time, an occlusive dressing with Vaseline gauze should be applied directly on the incision site. No suturing was done for the TT insertion site. A follow-up CXR was performed after 4 hours (per the standard of care) and one-week post-removal of TT to assess complications. CXRs were analyzed for recurrent pneumothorax, hemothorax, hemopneumothorax, and empyema. For this study, early removal of TT was defined as within 3 days post-insertion, whereas TT removal after 3 days was considered late removal. Re-inserting a post-removal TT was left to the physician’s discretion whenever indicated.

Study outcome

The primary outcomes of the study were complications on follow-up (recurrent pneumothorax, recurrent hemothorax, or empyema) and the need for un-planned interventions (chest tube/pigtail tube re-insertion, therapeutic video-assisted thoracoscopic surgery, and thoracotomy).

The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). This prospective study was approved by the Research Ethics Committee of the Medical Research Center, Hamad Medical Corporation (MRC-01-20-032). Before recruitment, written informed consent was obtained from the patients. If the patient could not consent (i.e., a ventilated patient, next of kin, or a legally authorized representative was not available), deferred consent was taken initially.

Statistical analysis

Based on the average number of TT insertion post-trauma in HTC per year (150–180), we enrolled 150 consecutive eligible cases. Data were reported as percentages, mean ± standard deviation, median, and range where applicable. Post-TT removal complications and interventions were compared and analyzed according to the time of TT removal (early ≤3 days vs. late >3 days), TT output (<150 vs. 150–200 mL), tube size (≤28 vs. >28 Fr), and side of TT insertion (left vs. right). Pearson Chi-squared test and Fisher’s exact tests were applied to compare the groups. Yates corrected Chi-squared was used for cell value less than 5. Intention-to-treat analysis was followed. Two-tailed P values less than 0.05 were considered statistically significant. The Statistical Package for the Social Sciences (SPSS) for Windows V.21.0 (SPSS, Chicago, Illinois, USA) was used for the data analysis.

Results

During the study period, 154 patients with TT insertion were eligible for the study, of which 150 patients were consented and recruited. Among the four excluded patients, three had low GCS with no substitute decision maker, and one refused to participate. The median age was 34 (range, 15–78 years), and 93% of the patients were males.

Of the recruited patients, 174 TTs were analyzed: 126 patients with single TT and 24 patients with bilateral (n=48) TTs. The median size of the TT was 28 Fr (12–36 Fr). Drains were almost equally distributed between right side TT (n=90) and left side TT (n=84). One hundred and twenty-three TTs were inserted in the Trauma Resuscitation Unit, 38 in the Trauma Intensive Care Unit (TICU), seven intraoperative, three in the stepdown unit, two in the trauma ward, and 1 in the Emergency Department. Most patients were males (93%, n=140) with a median age of 34 years (range, 15–78 years), and the median BMI was 28.8 kg/m² (range, 14.8–44.2 kg/m²). Blunt thoracic trauma was observed in 135 patients (90%), 16% had isolated chest trauma (n=24), and the median Injury Severity Score (ISS) was 24 (range, 4–54). Motor vehicle collision (32%) was the most common mechanism of injury, followed by falls (22%), as shown in Figure 2. The chest AIS values were comparable among all the study comparative groups.

Figure 2 Mechanism of injury.

Figure 3 shows the underlying pathology for TT insertion. In this study, 69 TTs (40%) were inserted to treat pneumothorax. Additionally, 48 TTs (28%) were inserted for hemothorax, while 25 TTs (14%) were used to treat cases of hemo-pneumothorax. The empirical tube insertion was performed in 18% (32 TTs) of those who either had a prehospital needle decompression or had a TT inserted in the Trauma Resuscitation Unit for extremely unstable vital signs or hypoxia. Following the study protocol, we successfully removed 105 TTs (60%) within 3 days post-insertion (early group). The remaining 69 tubes (40%) were removed after the third-day post-insertion (late group; Figure 4).

Figure 3 Underlying cause of thoracostomy tube insertion.

Figure 4 Number of thoracostomy tubes removed based on the day of admission.

In the late removal group, the most common cause for delayed removal of TT was an output of more than 200 mL in the last 24 hours, observed in 34 tubes (49%). Abnormal CXR was the second leading cause in 19 tubes (28%). It is worth mentioning that another 16 TTs had delayed removal for other reasons, such as pending surgery, pending magnetic resonance imaging scanning, traveling abroad by air, or at a treating physician’s discretion.

Seventy percent (n=121) of all TTs were removed in the TICU, while the remaining 30% were removed either in the trauma step-down unit or the ward.

Table 1 shows a comparison based on the timing of TT removal concerning complications and need for interventions post-TT removal. There was a slight increase in the number of patients with recurrent pneumothorax in the early removal group compared to the late removal group (P=0.09). However, the two groups did not differ regarding the rate of post-removal intervention.

Table 2 shows complications and interventions based on TT output for the last 24 hours before the removal of TT. The rate of recurrent pneumothorax (22.2% vs. 5.1%; P=0.02) and TT re-insertion (11.1% vs. 0.0%; P=0.002) were significantly higher in patients with TT output 150–200 mL as compared to those with lesser TT output (<150 mL).

Tables 3,4 compare complications and the need for interventions post-TT removal based on the size and side of the TT insertion. There was no significant difference in complications or interventions post-TT removal.

BMI (under vs. above 30 kg/m²) had no significant impact on the recurrent pneumothorax occurrence following TT removal (P=0.30).

The study analysis showed that adding an extra day to assess the patients for TT removal, i.e., 72 hours rather than 48 hours, we could safely remove 76% of the tubes (16% more). This approach resulted in one additional case of recurrent pneumothorax, one recurrent hemothorax, and one intervention (re-insertion of a pigtail drain was performed at the physician’s discretion). All these complications did not decrease the protocol safety from the 48-hour time window. On the other hand, more patients were free from TTs, fewer pain medications were needed, and early ambulation facilitated earlier hospital discharge. It is worth mentioning that in our study, the exact hospital length of stay (HLOS) was not calculated accurately because more than 90% of our patients had multi-system trauma, which could result in longer hospital stays. No further measures were required to treat thoracic trauma in addition to chest drainage in the study cohort, e.g., video-assisted thoracoscopic surgery (VATS) or surgical thoracotomy.

Discussion

The current research intended to establish a standardized procedure for early TT removal at a level 1 trauma center and to provide evidence regarding the safety of this practice. Early chest tube removal (≤3 days post-insertion) is feasible, and the rates of complications and interventions are comparable to late TT removal group.

Most thoracic injuries can be treated effectively with basic medical procedures such as inserting TT to drain fluid, analgesics, and breathing exercises without complex surgical procedures (14). Despite the concurrent literature having comprehensive guidelines for TT insertion, there was no well-established protocol for early removal of TT in trauma patients when we started our study. Therefore, having a well-defined, protocolized, and safe approach would help improve and secure the efficiency of removing TTs, hopefully leading to a lower rate of complications and the need for interventions post-TT removal.

Nevertheless, another study with almost the same protocol from Good Samaritan Regional Medical Center in the USA was recently published (15). The study recruited 145 patients, 45 of whom were in the pre-cohort category, unlike our study. Although they used a one-day post-insertion assessment to remove the chest drain, their results were comparable to ours and promising.

Notably, it is always helpful to implement a standardized institutional evidence-based protocol for any intervention. Our prior work testing a protocol for TT insertion in trauma patients reported a decrease in the rate of complications per TT from 12.6% in 2008 to 4.4% in 2014 after standard protocol implementation (16). The study concludes that standardized management of trauma patients who required TT insertions leads to fewer complications, better management, and better outcomes. Therefore, this suggests a significant requirement for a protocol for removing TT in chest trauma patients. Martin et al. studied patients with chest trauma (blunt 87%). They concluded that the TT management protocol resulted in a complication rate of 4.8% with a mean length of TT placement of 5.9±4.3 days (13). This rate was lower than the complication rate of Menger et al., which was 22% (17). The author suggested the consideration of chest AIS for the development of TT guidelines. In our study, the mean chest AIS was comparable in the study groups (3.07 vs. 3.20, P=0.35).

The management and timing of TT removal can often vary based on a physician’s level of training and experience (9). Physicians may advocate the removal of TT as early as possible (18). Moreover, placement of a chest tube for a longer duration may increase the risk of infection, worsening pain, and may lead to prolonged hospitalization (19). Recurrent pneumothorax is a prevalent complication after TT removal, with a reported occurrence rate ranging from 5% to 32% (20). In our study, the overall rate of recurrent pneumothorax was 6.9%, within the reported range. Although the results were insignificant, there was a clear trend towards an increase in pneumothorax in the early removal group.

Many guidelines have focused on the necessity of having no air leak from the TT for at least 24 hours before removal (21). The same argument could happen when deciding when a CXR is needed and how often to do it. Another argument is when and how long the TT should be off suction and when the next CXR should be done. Patients’ follow-up post-TT removal differs between elective thoracic surgery, traumatic pneumothorax, or spontaneous pneumothorax. Regarding trauma patients, there is a scarcity of level III evidence to guide the TT removal decision (12).

There is a lack of high-quality clinical studies, mainly double-blind clinical trials or meta-analyses, that provide definitive recommendations on the appropriate timing and indications for removing a TT (12,22). Although there is a low level of evidence, the literature shows that the minimum accepted time to assess the TT for removal is 48 hours post-insertion (12). The usual practice in many institutes is reassessing and removing TT between 3–5 days (12). Using a standardized protocol allowed us to successfully remove 60% of TTs within 3 days post-insertion. The most common cause for delayed removal of TT was an output of >200 mL within 24 hours. The management and removal of a TT are primarily determined by the amount of output from the drain (22-24). We chose the maximum TT output of 200 mL over the last 24 hours based on the pleural fluid’s physiological production rate of 0.15 mL/kg/hour. For example, an adult weighing 70 kg can produce about 250 mL/24 hours (25). Moreover, few studies agreed upon the daily TT output volume and rate (output <200 mL/day was safe as output <150 mL/day) (13,22-24,26).

Regarding complications after TT removal, such as recurrent hemothorax and pneumothorax, our analysis has no statistical difference between the early removal of TT and late removal after 3 days of insertion. A previous prospective study found that removing the chest tube at the end-inspiration phase with suction after 24–48 hours is associated with a lower rate of recurrent pneumothorax and a shorter hospital stay (27). An earlier study demonstrated that the incidence of complications such as hemothorax and pneumothorax did not show any significant difference between patients who had TT removed 5–7 days after insertion while still on ventilation and those who had their TT removed immediately after being disconnected from the ventilator (9). It has been reported that placing chest tubes on continuous low-pressure suction after penetrating chest trauma is an effective management approach as it reduces the TT removal time, hospital stay, and need for surgery for hemothorax (28). A recent prospective observational study suggests that minimizing the duration of drain placement and avoiding drain repositioning may help reduce pleural complications in trauma patients (29).

Limitations

The study sample size was limited by the average number of cases with TT insertion per year in this single center. Moreover, the study power was a limiting factor in ensuring better association and solid conclusion. Therefore, the study protocol needs to be validated in a multicenter trial. The HLOS was not considered an outcome for polytrauma patients. A comparison with those who had TT removal before this protocol implantation (i.e., comparing pre- and post-implementation outcomes) would be informative. Most patients (84%) had polytrauma rather than isolated chest injury. Hence, the association between TT removal and hospital stay is difficult to establish as patients may stay for a different cause, such as head injury or orthopedic trauma. Pain assessment from TT placement could not be established well, as most of our patients had other associated injuries. This protocol needed a clear policy for patients with bilateral TT insertion. However, the second tube was removed the next day or even later. Therefore, we need to update the protocol for the bilateral TT so that the second TT can be removed once the post-removal CXR of the first TT is interpreted as normal. No pre-existing conditions apart from the BMI, such as diabetes mellitus, hypertension, and previous lung diseases, were recorded and compared between the groups. Future protocol might benefit from stricter fluid output thresholds to minimize complications and integrate a more conservative approach, especially for patients with borderline fluid output or radiographic findings strategies to avoid re-insertion, such as extending the observation period before removal in borderline cases. Moreover, it is Eastern Association for the Surgery of Trauma (EAST) and American Association for the Surgery of Trauma (AAST) guidelines that all TT insertions after chest trauma should be under mild suction (−15 to −20 mmHg).

Conclusions

Despite the occurrence of non-significant post-removal events in the early TT-removal group, the rate of post-removal interventions was comparable to that of the late group. Moreover, the patient’s BMI, laterality of tube insertion, and tube size were not associated with complications or post-removal interventions. The TT-removal protocol can be implemented in high-volume trauma centers to further validate its safety and effectiveness. More studies with larger sample sizes and multicenter participation would be beneficial to validate these findings.

Acknowledgments

We thank the Qatar National Trauma Registry staff and healthcare providers at the Hamad Trauma Center and the Medical Research Center for their support.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1229/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1229/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1229/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1229/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study conformed to the provisions of the Declaration of Helsinki (as revised in 2013). This prospective study was approved by the Research Ethics Committee of the Medical Research Center, Hamad Medical Corporation (MRC-01-20-032). Before recruitment, written informed consent was obtained from the patients. If the patient could not consent (i.e., a ventilated patient, next of kin, or a legally authorized representative was not available), deferred consent was taken initially.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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