Since 1963, Cook Medical has been a champion of minimally invasive treatment options for patients. In the case of the centesis and drainage procedural areas, the healthcare industry discussion has largely centered around the efficacy of large-bore versus small-bore catheters.
Within the last decade, there have been several clinical studies published in peer-reviewed journals stating the increased efficacy and improvement of small-bore catheters versus large-bore catheters for pleural and pericardial drainage procedures.
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“Two-year experience of using pigtail catheters to treat traumatic pneumothorax: a changing trend,” published in The Journal of Trauma, was a study published in 2011 that compared small-bore, 14 Fr pigtail catheters to chest tubes in patients with nontraumatic pneumothoraces.
A chest tube “because of its large caliber and significant trauma during an insertion, can cause pain, prevent full lung expansion, and worsen pulmonary outcome. Pigtail catheters are smaller and less invasive,” the introduction to the study states.¹
The charts of 9,624 trauma patients over a two-year period at a Level I trauma center were evaluated. The study concluded that the “demographics, tube days, need for mechanical ventilation, and insertion-related complications were similar,” using these characteristics to determine that pigtail catheters have a comparable efficacy to chest tubes.1
Similar efficacy results were found in another study published in The Journal of Trauma and Acute Care Surgery in 2012, titled “14 French pigtail catheters placed by surgeons to drain blood on trauma patients: is 14 Fr too small?”
14 Fr, small-bore pigtail catheters were used to test the hypothesis that they “can drain blood as well as large-bore 32 to 40 Fr chest tubes” in patients with traumatic hemothorax or hemopneumothorax.2
Patients receiving treatment at a Level I trauma center were studied over a period of 30 months. “Our primary outcome of interest was the initial drainage output. Our secondary outcomes were tube duration, insertion-related complications, and failure rate,” the authors stated in the study.2
The results of the study concluded that the “tube duration, rate of insertion-related complications, and failure rate were all similar” in both types of catheters, with small-bore pigtail catheters draining blood at a comparable rate to large-bore chest tubes.2
36 to 40 Fr chest tubes were also compared to small-bore, pigtail catheters in a similar study also published in The Journal of Trauma and Acute Care Surgery, titled “Does size matter? A prospective analysis of 28-32 versus 36-40 French chest tube size in trauma.”
There was no difference in the efficacy of drainage or rate of complications.3
In this study, the authors claim that “the optimal chest tube size for the drainage of traumatic hemothoraces and pneumothoraces is unknown.”3 This study was designed to compare the efficacy of small-bore versus large-bore drainage catheters in patients with thoracic trauma.
Data were gathered on 293 patients that required open chest tube drainage within 12 hours of admission to a Level I trauma center.
“Clinical demographic data and outcomes including efficacy of drainage, complications, retained hemothoraces, residual pneumothoraces, need for additional tube insertion, video-assisted thoracoscopy, and thoracotomy were collected and analyzed by tube size,” the authors said.3 Small-bore catheters, ranging from 28 to 32 Fr, were compared with large chest tubes, ranging from 36 to 40 Fr; a total of 353 catheters, 186 small and 167 large, were placed during the study.
The authors determined that the need for tube reinsertion, image-guided drainage, video-assisted thoracoscopy, and thoracotomy were the same when comparing small-bore to large-bore catheters.3
“For injured patients with chest trauma, chest tube size did not impact the clinically relevant outcomes tested. There was no difference in the efficacy of drainage, rate of complications including retained hemothorax, need for additional tube drainage, or invasive procedures,” the study concluded.3
Echoing the claim that “the optimal chest tube size for the drainage of traumatic hemothoraces and pneumothoraces is unknown,”3 a study published in Clinics in Chest Medicine aimed to generalize the use of small-bore catheters for drainage procedures, including pleural infection.
In “Straightening out chest tubes: What size, what type, and when,” the authors stated that “small-bore tubes (<14 Fr) are effective for most pleural processes. Various types of pneumothorax and malignant and infected complicated pleural effusions have been successfully managed with small-bore chest tubes.”4
Abundant literature supports a paradigm shift towards the more routine use of small-bore chest tubes for managing pleural disease.4
The authors also stated that benefits of using small-bore drainage catheters include patient comfort and ease of catheter placement, as most small-bore tubes can be placed under ultrasound guidance using the Seldinger technique.4
The study concluded that small-bore chest tubes “are effective for most pleural diseases. Various types of pneumothorax and malignant and infected complicated pleural effusions have been successfully managed with small-bore chest tubes…abundant literature supports a paradigm shift towards the more routine use of small-bore chest tubes for managing pleural disease.”4
A study published in CHEST, titled “The relationship between chest tube size and clinical outcome in pleural infection,” also aimed to determine the optimal choice of drainage catheter sizes for pleural infection.
This multicenter study consisted of 405 patients and studied “the combined frequency of death and surgery, and secondary outcomes,” including hospital stay, change in chest radiograph, and lung function at three months, in patients who received a variety of sizes of chest tubes. In 128 of the 405 patients, a pain scale was also studied.
“There was no significant difference in the frequency with which patients either died or required thoracic surgery in patients receiving chest tubes of varying sizes,” the study noted, however, “pain scores were substantially higher in patients receiving (mainly blunt dissection inserted) larger tubes.”5
The study concluded that, “smaller, guide-wire-inserted chest tubes cause substantially less pain than blunt-dissection-inserted larger tubes, without any impairment in clinical outcome in the treatment of pleural infection.”5
Although the optimal chest drain size remains largely unknown, a study titled “Optimal chest drain size: the rise of the small-bore pleural catheter,” published in Seminars in Respiratory and Critical Care Medicine, argued that “objective data supporting the use of large-bore chest tubes is scarce.”6
The onus now is on those who favor large tubes to produce clinical data to justify the more invasive approach.6
In support of the efficacy of small-bore drains, the study stated, “Increasing evidence shows that small-bore catheters induce less pain and are of comparable efficacy to large-bore tubes, including in the management of pleural infection, malignant effusion, and pneumothoraces. The onus now is on those who favor large tubes to produce clinical data to justify the more invasive approach.”6
1. 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;71(5):1104-1107.
2. Kulvatunyou N, Joseph B, Friese RS, et al. 14 French pigtail catheters placed by surgeons to drain blood on trauma patients: Is 14-Fr too small? J Trauma Acute Care Surg. 2012;73(6):1423-1427.
3. Inaba K, Lustenberger T, Recinos G, et al. Does size matter? A prospective analysis of 28-32 versus 36-40 French chest tube size in trauma. J Trauma Acute Care Surg. 2012;72(2):422-427.
4. Mahmood K, Wahidi MM. Straightening out chest tubes: what size, what type, and when. Clin Chest Med. 2013;34(1):63-71.
5. Rahman NM, Maskell NA, Davies CW, et al. The relationship between chest tube size and clinical outcome in pleural infection. Chest. 2010;137(3):536-543.
6. Fysh ET, Smith NA, Lee YC. Optimal chest drain size: the rise of the small-bore catheter. Semin Respir Crit Care Med. 2010;31(6):760-768.