Welcome to the emDOCs Videocast! These videos will cover post summaries, takehomes on clinical condition, and EBM/guideline literature updates. Today we focus on management of hemothorax, specifically tube thoracostomy (TT) size and irrigation following tube placement.
Article #1: Lyons NB, Abdelhamid MO, Collie BL, Ramsey WA, O’Neil CF, Delamater JM, Cobler-Lichter MD, Shagabayeva L, Proctor KG, Namias N, Meizoso JP. 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.
Clinical Question:
- In adults with hemothorax, is small-bore TT (< 14F) as effective as large-bore TT (> 20F) for drainage?
Design:
- Registered systematic review and meta-analysis.
- Included RCTs and cohort studies evaluating adults with chest injury and hemothorax or hemopneumothorax receiving TT.
Outcomes:
- Primary: TT failure rate
- Secondary: ICU LOS, hospital LOS, drainage output, TT days, complications, pain
Results:
- 11 studies (2002-2020): 3 RCTs, 3 prospective/5 retrospective cohorts
- 1,847 patients and 1,972 tube thoracostomies (730 SBTT and 1,242 LBTT)
- Primary outcome: No difference in TT failure rate (17.8% vs. 21.5%, RR 1.1)
- Secondary:
- No difference in complications, LOS, mortality
- SBTT higher initial drainage; more insertion complications; less pain, VATS, TT days
Considerations:
- Study asks important question; classic teaching is to place a 36-40 Fr tube for HTX.
- 2021 EAST guidelines support SBTT for HTX based on very-low quality evidence.
- This SRMA was registered and followed PRISMA checklist.
- There was significant heterogeneity with only 3 RCTs.
- There were differences in patients including injury patterns, ages, and outcomes evaluated.
The Bottom Line
- SBTT may be as effective as LBTT for HTX, but higher quality data needed.
- In stable patients with HTX/HPTX who do not need emergent TT, consider SBTT
Article #2: Lyons NB, Collie BL, Cobler-Lichter MD, Delamater JM, Shagabayeva L, Tito-Bustillos L, Proctor KG, Valenzuela JY, Meizoso JP, Namias N. Thoracic irrigation for traumatic hemothorax: A systematic review and meta-analysis. J Trauma Acute Care Surg. 2025 Feb 1;98(2):337-343.
Clinical Question:
- In adults with hemothorax, irrigation following TT associated with reduce rates of TT failure and complication?
Design:
- Registered systematic review and meta-analysis.
- Included RCTs and cohort studies evaluating adults with hemothorax undergoing TT and irrigation versus no irrigation.
Outcomes:
- TT failure, complications, need for additional procedures, cost
Results:
- 6 studies: 4 prospective observational and 2 retrospective studies (no RCTs); 1,319 patients (513 received thoracic irrigation and 837 did not).
- Failure rate 10.7% in the irrigation group versus 18.2% in the control group.
- Control group (no irrigation) had more second chest tubes (5.3% versus 1.7%), VATS (9.9% versus 6%), and open thoracotomies (4% versus 1.4%), as well as a higher incidence of pneumonia (12.6 versus 7.6); no difference in empyema. Estimated cost higher in control group.
Considerations:
- Study asks important question.
- Limitations include observational data, heterogeneity, confounding with indication and selection bias.
- Unclear what TT size to use for irrigation (ranged between 14-36 Fr)and what volume (most used 1L).
The Bottom Line
- Promising results; irrigation may be associated with lower complication rates, need for additional procedures, and cost.
- Further study needed before routine use.
