It’s not the size, it’s how you use it (when it comes to chest tubes)

In fact, data suggests that simple manual aspiration is as effective at resolving a spontaneous pneumothorax as a traditional chest tube under the right circumstances, It is actually recommended (level A) by the British Thoracic Society (BTS) as first-line therapy for first-episode spontaneous pneumothorax as long as the patient is hemodynamically stable, the pneumothorax is 20-40% of lung volume, no more than 4L of air is removed, and there’s no tension.^[1],[2] That being said, the data here is exceptionally scarce – a Cochrane review from 2007 was only able to find 6 studies comparing manual aspiration to thoracostomy and determined that only 1 study was satisfactory. It did conclude (based on the one study) that aspiration has similar rates of success and eventual progression to surgery and decreases the need for admission, length of stay, and recurrence rates when compared to chest tubes.^[3] Our own Dr. Zehtabchi performed a systematic literature review, and based on 3 RCTs, came to similar conclusions: Aspiration decreased the need for hospitalization and need for analgesia.^[4] Small RCTs (one including 56 patients and one including 60 patients) do back this conclusion,^{[5], [6]} and it makes sense logically – a patient with a tube hanging out of their chest wall is more likely to experience painless and less likely to be sent home than someone without it.

I borrowed these excellent instructions (below) and illustrative pictures (above) from Repanshek et al.² NEJM also has an illustrative video on the procedure here.

Following the BTS guidelines, you decide to perform a needle aspiration by which you remove approximately 3L of air. The patient is symptomatically improved and symptoms do not recur during a 4-hour observation period. A repeat radiograph confirms lung expansion, and the patient is deemed reliable with good follow-up, so you discharge him home with instructions for re-evaluation in 24 hours.

Ah, that’s better.

OK, so you can potentially use needle aspiration for a spontaneous pneumothorax. But what if your patient has just been smacked by a bus? What if there’s the potential for blood in the chest instead of just air?

There’s no large, well-designed trials on needle aspiration for traumatic pneumothoraces or hemothoraces, but there is talk of potentially using small-bore, 14 french (Fr) pigtail catheters in lieu of the larger, 28-40 Fr chest tubes traditionally placed. One of the main selling points is that smaller tubes are less painful for the patient when inserted.^[7] The data is, again, less-than-robust here – 2 retrospective studies demonstrated that pigtail catheters placed for traumatic pneumothorax were as effective as traditional chest tubes at lung re-expansion without complications and were associated with a shorter duration of stay.^[8],[9] The caveat here is that pigtails were typically placed in patients that had lower injury severity scores and later in the course, suggesting the patients were potentially not as sick. In terms of drainage for hemothorax, data is even sparser. One study of 227 patients in whom either chest tubes or pigtail catheters were placed for hemothorax concluded that pigtails had similar initial rates of blood output as well as length of stay, duration of tube dwell time, failure rate, complications, and mortality.^[10] In this trial, pigtails were more likely to be placed for blunt rather than penetrating trauma, and again, pigtails were placed later in the course. This data is flawed and difficult to interpret due to inherent biases, but it does at least suggest that in a pinch, a smaller tube may be as effective as the 40 Fr pipe that the trauma team is likely going to want to place.

Manual aspiration seems to be effective in treating spontaneous pneumothorax. It is also less painful for patients and may decrease hospital length of stay and/or the need for admission in the first place (more on discharging pneumothoraces from the ED later – stay tuned). For traumatic pneumothorax and hemothorax, large-bore chest tubes are probably still the way to go (at least until there’s better data out there) unless you’re feeling particularly gutsy.

Thanks again to Dr. deSouza and Shibata for their editing.