Pigtail Insertion

It’s a typical busy Saturday night in your ED. The next chart you pick up is a 15-year-old male with cough shortness of breath and chest pain for one day. He is tall, with normal vitals and in no distress, and you note decreased breath sounds on his right side. Chest X-ray confirms it: pneumothorax.

A detailed guide for small-bore catheter insertion for the treatment of pneumothorax in the emergency department.

It’s a typical busy Saturday night in your ED. The next chart you pick up is a 15-year-old male with cough shortness of breath and chest pain for one day. He is tall, with normal vitals and in no distress, and you note decreased breath sounds on his right side. Chest X-ray confirms it: pneumothorax. As you begin thinking about how best to manage him, the trauma team is paged overhead. EMS brings in a 40-year-old female pedestrian who was struck by a car. She has normal vitals and is complaining of left rib pain and shortness of breath.  On your extended fast exam you detect no lung sliding on the left, and your suspicion of traumatic pneumothorax is confirmed by chest X-ray. Though you are expert at conventional tube thoracostomy you wonder if there are other, perhaps less painful or traumatic methods for relieving the pneumothoraces of these two stable patients.

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Introduction

Traditionally, patients with pneumothoraces seen in the ED receive tube thoracostomy.  However, in recent years, guidelines and statements from American College of Chest Physicians (ACCP) and British Thoracic Society (BTS) stress the value of observation, repeat imaging and prompt follow-up for stable, asymptomatic patients with no underlying lung disease or trauma. An ACCP consensus statement further clarified observation for 3-6 hours in an asymptomatic patient with less than 3 cm PTX without progression on subsequent expansion on CXR may be safely discharged with prompt follow-up and repeat radiography within 48 hours. In patients who do not qualify for conservative therapy, alternative therapies are simple aspiration in select candidates (stable patients with primary spontaneous pneumothorax), and increasingly, small-bore chest tubes with Heimlich valves for a wider variety of patients.

Small-bore chest tubes – also referred to as pigtail catheters – are being used to relieve both spontaneous and in some cases, traumatic pneumothorax. These pigtails are placed with a Seldinger catheter-over-wire technique very similar to the central venous catheter insertion.  Advantages of the percutaneous placement of small bore chest tubes are: less pain, no need for tissue dissection, less scarring and no need for suturing upon chest tube removal. The technique decreases the risk of complications and shortens (or eliminates) hospital admission.

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Left: For PTX, optimal placement is in the safety triangle, bordered by the lateral edge of the pectoral muscle, the lateral edge of the latisimus dorsi and a line along the fifth intercostal space at the level of the nipple.

Right: Anesthetize the skin and deeper tissues with increasingly larger needles inserted over the superior aspect of the rib to minimize damage to the neurovascular bundle which travels along the inferior aspect of the rib.

Indications

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Chest tubes have traditionally been placed to evacuate pneumothoraces, hemothoraces, and pleural effusions as well as provide pleurodesis. While rapid tube thoracostomy is still preferred in an unstable patient, pigtail catheters with Heimlich valves are increasingly preferred to large bore chest tubes in the treatment of pneumothoraces and simple pleural effusions due to their less traumatic less painful insertion and lower cost.  They also offer decreased risk of hemorrhage in anticoagulated patients or those with bleeding diathesis.

Small-bore catheters (6-12 F) were compared to traditional large-bore catheters (20-32 F) in a recent retrospective study of UK patients with spontaneous pneumothoraces (Benton 2009). Successful resolution was seen at the same rate for both groups (80-88%), but the large-bore patients had a higher complication rate (32%) with more infections (24%). The leading complication among small-bore catheter patients was dislodgement (21%).

Attachment of a small-bore catheter to a Heimlich valve offers an additional advantage. The Heimlich valve is a one-way flutter valve that allows air to exit the thorax with exhalation, but closes to prevent pneumothorax expansion during inhalation. A smaller retrospective study of Canadian patients with spontaneous pneumothoraces receiving 8 F small-bore catheters with Heimlich valves (Hassani 2009) showed similar success and complication rates to the Benton study, and further noted that 81% of patients receiving this intervention were discharged directly from the ED.

A restrospective review of 221 trauma patients at a level 1 trauma center who required chest tube or pigtail catheter placement for traumatic pneumothorax by the trauma team (EP & surgeons) as initial patient management showed no significant differences in mechanical ventilations use, number of tube days, and the number of ICU days (Kulvatunyou 2011).  In fact, another retrospective review of 202 stable trauma patients demonstrated the benefit of pigtail catheters to chest tubes.  In this study, pigtails and chest tubes were placed for similar indications (pneumothorax, hemothorax, empyema and effusion) and overall complications rates were similar among the two groups except for the rate of fibrothorax which was significantly lower for pigtails than chest tubes (Rivera 2009).  Despite these and several other studies comparing pigtail catheters to chest tubes, further research, particularly prospective studies, need to be performed to further characterize indications for pigtails versus chest tubes.

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As fluid flow is dependent on tube’s internal diameter and fluid viscosity, pigtails have generally been restricted to draining air or thin, free-flowing liquids. Thus, optimal candidates for pigtails are stable patients who present to the ED with pneumothorax or new pleural effusion. In the case of pleural effusion, a lateral decubitus CXR can be obtain to assess the mobility and thus viscosity of the effusion as pigtails preform better with less viscous fluids.

Remove the syringe from the needle and pass the guide wire in just enough to clear the needle. Most of the guide wire should be hanging out. If inserted too far it will be difficult to direct the pigtail catheter superiorly into the apex of the thorax.

Pigtail catheters in pediatric patients

The literature evaluating large- versus small-bore chest tubes in pediatric patients is less robust than in adults. However several studies (Dull 2002, Kuo 2013) suggest that, as with adults, pigtails have similar efficacy and complication rates to conventional chest tubes in treating spontaneous pneumothoraces.

Left: Make a small incision in the skin adjacent to the guide wire just as in central line insertion, then pass the dilator over the wire and into the pleural space. You should feel the dilator “ give way” once you are in.  Check that the guide wire is moving freely in and out of the dilator throughout this process to avoid kinking the wire.

Right: Remove the syringe from the needle and pass the guide wire in just enough to clear the needle. Most of the guide wire should be hanging out. If inserted too far it will be difficult to direct the pigtail catheter superiorly into the apex of the thorax.

Case Conclusions

Both patients receive percutaneously placed pigtail catheters. The procedures unfold with minimal discomfort, and they appreciate their mobility and improvement of symptoms. As their pneumothoraces resolve, they are discharged home with Heimlich valves and comprehensive instructions for maintenance (keeping the surrounding skin clean, keeping the outlet unobstructed) and have clinic follow-up arranged for pigtail removal a few days later.

Step By Step

1. Place the patient in either lateral recumbent position or supine, with the head of the bed up 40-45 degrees (best for pneumothorax) or in a sitting position for posterior access to effusions posteriorly.
2. Determine the best place for insertion. For PTX, optimal placement is in the safety triangle, bordered by the lateral edge of the pectoral muscle, the lateral edge of the latisimus dorsi and a line along the fifth intercostal space at the level of the nipple. Insertion here minimizes the risk of damage to nerves, vessels and organs.  For effusions, the placement can be altered based on the locations of the fluid on ultrasound (US). Although no studies to date have been done comparing ultrasound guidance to blind placement of pigtails catheters, studies with thoracentesis have demonstrated reduced complications with ultrasound guidance.
3. Sterilize and drape.
4. Measure the small bore catheter (6-12F) against the chest to determine how far in it should be inserted for placement into the superior aspect of the chest with all side holes within the pleural cavity. Remember that pigtails can easily be drawn back but cannot be inserted further in after the procedure is completed.
5. Anesthetize the skin and deeper tissues with increasingly larger needles inserted over the superior aspect of the rib to minimize damage to the neurovascular bundle which travels along the inferior aspect of the rib. Anesthetize to the parietal pleura. The pleura is particularly sensitive; be generous with anesthetic at this location.
6. Load the finder needle with a few ml of sterile water so that you can visualize aspiration of air during insertion. Insert the needle over the superior aspect of the rib while drawing back. Once in the pleural space, the syringe plunger will give way aspirating bubbles in pneumothorax and pleural fluid in effusions.
7. Remove the syringe from the needle and pass the guide wire in just enough to clear the needle. Most of the guide wire should be hanging out. If inserted too far it will be difficult to direct the pigtail catheter superiorly into the apex of the thorax.
8. Removed the needle leaving the wire in place. Make a small incision in the skin adjacent to the guide wire just as in central line insertion, then pass the dilator over the wire and into the pleural space. You should feel the dilator “ give way” once you are in.  Check that the guide wire is moving freely in and out of the dilator throughout this process to avoid kinking the wire.
9. Pass the pigtail and its trocar over the wire, making sure that the last side hole is within the pleural space.
10. Remove the trocar and guide wire, leaving the pigtail catheter in place, and suture the pigtail to the chest wall in a similar manner to conventional chest tubes.
11. Place the Heimlich (flutter) valve onto the end of the pigtail catheter and either leave it open to air or connect to water seal with suction.
12. Obtain a confirmatory x-ray after the procedure is complete. The entire procedure should take 10-15 minutes.
13. A demonstration of small-bore tube thoracostomy from Al Sacchetti: http://www.youtube.com/watch?v=xsB9MkuCQE4

References

1. Benton IJ, Benfield GF. Comparison of a large and small-calibre tube drain for managing spontaneous pneumothoraces. Respir Med. 2009 Oct;103(10):1436-40.
2. Dull KE, Fleisher GR. Pigtail catheters versus large-bore chest tubes for pneumothoraces in children treated in the emergency department. Pediatr Emerg Care. 2002 Aug;18(4):265-7.
3. Gammie JS et al. The pigtail catheters for pleural drainages: a less invasive alternative to tube thoracostomy. JSLS. 1999 Jan-Mar;3(1):57–61.
4. Hassani B, Foote J, Borgundvaag B. Outpatient management of primary spontaneous pneumothorax in the emergency department of a community hospital using a small-bore catheter and a Heimlich valve. Acad Emerg Med. 2009 Jun;16(6):513-8.
5. Jones PW, et al. Ultrasound-guided thoracentesis: is it a safer method? Chest. 2003 Feb;123(2):418-23.
6. Kulvatunyou N, et al. A prospective randomized study of 14-French pigtail catheters vs 28F chest tubes in patients with traumatic pneumothorax: impact on tube-site pain and failure rate. EAST Annual Surgical Assembly, Oral paper 12, Jan 17, 2013.
7. Kulvatunyou N, Vijayasekaran A, Hansen A, et al. Two-year experience of using pigtail catheters to treat traumatic pneumothorax: a changing trend. J Trauma. 2011 Nov;71(5):1104-7.
8. Kuo HC, et al. Small-bore pigtail catheters for the treatment of primary spontaneous pneumothorax in young adolescents. Emerg Med J. 2013 Mar;30(3):e17.
9. Laws D et al. BTS guidelines for the insertion of a chest drain. Thorax. 2003 May;58 Suppl 2:ii53-9.
10. Liu YH, et al. Ultrasound-guided pigtail catheters for drainage of various pleural diseases. Am J Emerg Med. 2010 Oct;28(8):915-21.
11. Repanshek ZD, Ufberg JW, Vilke GM, Chan TC, Harrigan RA. Alternative Treatments of Pneumothorax. J Emerg Med. 2013 Feb;44(2):457-466.
12. Rivera L, O’Reilly EB, Sise MJ, et al. Small catheter tube thoracostomy: effective in managing chest trauma in stable patients. J Trauma. 2009 Feb;66(2):393–9
13. Thomsen TW, et al. Thoracentesis, Videos in Clinical Medicine. N Engl J Med. 2006 Oct 12;355(15):e16.

Drs. J. Michael Guthrie, Ben Azan and George Lim are residents at Mount Sinai Department of Emergency Medicine