When U.S. Air Force Maj. Regan Lyon, MD, FACEP, was in medical school and residency, she nearly always inserted chest tubes using large-bore catheters. But, increasingly, literature and experience has shown her that small-bore catheters can be just as effective for most patients.
Now it’s just a matter of getting that word out to other emergency physicians, Dr. Lyon said during her ACEP19 presentation, “Chest Tubes – Pearls and Pitfalls.”
“We were taught large bore all the time,” Dr. Lyon said. “I put in maybe one pigtail (catheter) in my whole residency because it just wasn’t utilized. And so a lot of people who aren’t necessarily reading up on the data may still be doing that. But we can save our patients a lot of pain, and even some time for us.”
Dr. Lyon aid that for small, spontaneous, stable pneumothoraces, she recommends putting patients on oxygen and reviewing before immediately moving to a chest tube insertion.
“For simple pneumothoraces alone – spontaneous, secondary, traumatic, etc. – you could probably just use a small-bore catheter,” she said. “The only thing you probably need a large bore chest tube anymore is an empyema and some hemothoraces.”
Dr. Lyon said that reducing pain for patients is a major factor in considering which size chest tube to select.
“Pain management, however you choose it, is going to be important,” she said. “This is not a benign procedure for a patient, especially an awake patient.”
Aside from tube-size selection, Dr. Lyon suggested emergency physicians consider using ultrasound to guide insertion, as that helps lessen discomfort to patients. In addition, doctors need to think through what type of pain control they prefer.
“Local infiltration of lidocaine or some kind of anesthetic over the rib should probably always be used, if you have the time to be able to do it,” Dr. Lyon added.
Dr. Lyon said she often will use a systemic approach – ketamine or fentanyl, for example – but added that emergency physicians need to consider how long the patient has been exhibiting symptoms. If a patient’s injury occurred too long a time before the administration of pain control, there could be respiratory complications.
A middle ground between treatments such as lidocaine and fentanyl would be a regional technique, such as a paravertebral block. Dr. Lyon joked with the audience that while those blocks can take a long time, they are effective.
“If you have the skills and you’ve ben trained in that, absolutely,” she said. “It does work. I make fun of the anesthesiologists, but it absolutely does work.”
Dr. Lyon said that there are reasons to use large-bore catheters, but emergency physicians need to make sure they think through those cases. In many cases, a quick consultation with surgeons may help steer the decision.
“The only thing you probably need a large bore chest tube anymore is an empyema and some hemothoraces,” she said. “The literature, especially the trauma literature, is starting to suggest that even in traumatic hemothoraces we can use pigtail catheters and small-bore chest tubes.”
Richard Quinn is a freelance writer from New Jersey.