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Are chest radiographs routinely necessary following thoracostomy tube removal?
Preeyacha Pacharn1, Daniel N D Heller, Bamidele F Kammen
1Department of Radiology, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143-0628, USA.
Insights
Routine chest X-rays after chest tube removal may not be necessary for all pediatric patients. Clinical signs and symptoms effectively identify most significant pneumothoraces, suggesting selective imaging may be appropriate.
Area of Science:
- Pediatric Medicine
- Thoracic Surgery
- Diagnostic Imaging
Background:
- Chest radiographs (CXRs) are standard post-thoracostomy tube removal in pediatric patients to detect pneumothorax (PTX).
- The necessity of routine CXRs in all pediatric patients after chest tube removal warrants investigation.
Purpose of the Study:
- To evaluate the predictive value of clinical signs and symptoms for detecting pneumothorax (PTX) in pediatric patients after chest tube removal.
- To inform decisions regarding the routine use of post-procedure chest radiography.
Main Methods:
- Retrospective review of 374 pediatric patients undergoing cardiac surgery with chest tube placement.
- Analysis of CXR reports and chart reviews to correlate clinical presentation with PTX findings.
- Quantification of PTX size and assessment of clinical interventions.
Main Results:
- 13.6% of patients developed pneumothorax (PTX) within 6 hours of chest tube removal.
- Clinical signs and symptoms of respiratory distress were present in most patients requiring major intervention for PTX.
- Large or moderate PTX, or small PTX that enlarged, prompted significant clinical interventions.
Conclusions:
- Clinical assessment is highly sensitive for identifying significant pneumothoraces in pediatric patients post-thoracostomy tube removal.
- Consideration should be given to reserving routine chest radiography for select patient groups, such as those with symptoms or unstable cardiovascular status.
Objective:
Chest radiographs (CXRs) are routinely obtained at many institutions in all pediatric patients following thoracostomy tube removal to search for pneumothorax (PTX). To aid in evaluating the necessity of this practice, this study investigates whether clinical signs and symptoms may be a sensitive predictor of PTX in such patients.
Materials And Methods:
Reports from CXRs obtained following chest tube removal in all pediatric patients (374 patients) who underwent cardiac surgery with chest tube placement over 1 year were reviewed. For cases with reported PTX, the PTX was quantified and chart review was performed to assess whether signs and symptoms of PTX preceded the CXR result.
Results:
Fifty-one of 374 children (13.6%) had a radiographically defined PTX within 6 h after thoracostomy tube removal. The PTX was large (>40%) in 2 children, moderate (20-40%) in 5 children, and small (<20%) in 44 children. Symptoms (dyspnea, tachypnea, respiratory distress) or signs (increased oxygen requirement, worsening arterial blood gas and/or hypotension) of respiratory distress were present at the time of the initial CXR in six of seven patients, who later underwent a major clinical intervention, and in one patient who did not. Major clinical interventions were performed in all patients with a large PTX, four of five patients with a moderate PTX, and one patient with a small PTX that later enlarged.
Conclusions:
Clinical signs and symptoms identified nearly all patients with significant pneumothoraces. Future prospective investigations may examine reserving chest radiography following chest tube removal for select groups, such as symptomatic patients or those with tenuous cardiovascular status.