Chest
Volume 137, Issue 3, March 2010, Pages 536-543
Journal home page for Chest

Original Research
Interventional Pulmonology
The Relationship Between Chest Tube Size and Clinical Outcome in Pleural Infection

https://doi.org/10.1378/chest.09-1044Get rights and content

Background

The optimal choice of chest tube size for the treatment of pleural infection is unknown, with only small cohort studies reported describing the efficacy and adverse events of different tube sizes.

Methods

A total of 405 patients with pleural infection were prospectively enrolled into a multicenter study investigating the utility of fibrinolytic therapy. The combined frequency of death and surgery, and secondary outcomes (hospital stay, change in chest radiograph, and lung function at 3 months) were compared in patients receiving chest tubes of differing size (χ2, t test, and logistic regression analyses as appropriate). Pain was studied in detail in 128 patients.

Results

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 (< 10F, number dying or needing surgery 21/58 [36%]; size 10-14F, 75/208 [36%]; size 15-20F, 28/70 [40%]; size > 20F, 30/69 [44%]; χ2trend, 1 degrees of freedom [df] = 1.21, P = .27), nor any difference in any secondary outcome. Pain scores were substantially higher in patients receiving (mainly blunt dissection inserted) larger tubes (< 10F, median pain score 6 [range 4-7]; 10-14F, 5 [4-6]; 15-20F, 6 [5-7]; > 20F, 6 [6-8]; χ2, 3 df = 10.80, P = .013, Kruskal-Wallis; χ2trend, 1 df = 6.3, P = .014).

Conclusions

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. These results suggest that smaller size tubes may be the initial treatment of choice for pleural infection, and randomized studies are now required.

Trial registration

MIST1 trial ISRCTN number: 39138989.

Section snippets

The MIST1 Trial

The MIST1 trial2 was a double-blind, placebo-controlled comparison of intrapleural streptokinase with placebo in pleural infection. Intrapleural streptokinase was shown not to improve outcome, and so the results relating to chest tube size are not confounded by a treatment effect. Four hundred fifty-four patients were recruited from 52 UK centers, including both general and teaching hospitals. Patients with pleural fluid that was macroscopically purulent, positive on culture for bacterial

Subjects

Detailed chest tube data, including exact tube size, were available on 405 (89%) of the 454 subjects (Table 1). Where tube size was not recorded, this was usually because the insertion had been by an admitting physician not involved in the trial. The distribution of the chest tube sizes used in the whole group and in the two insertion methodology subsets is shown in Table 2.

Primary Analysis

There was no difference in the frequency with which patients either died and/or required thoracic surgery at 12 months in

Discussion

Our study has shown that the clinical outcome in patients treated with different chest tube sizes for pleural infection is similar, but smaller-size tubes cause less pain.

This difference in pain is substantial and clinically significant. During chest tube insertion and while the tube was in situ, 22/41 (54%) of patients receiving a chest tube ≥ 15F experienced moderate/severe pain, compared with only 21/77 (27%) of patients treated with a tube < 15F (χ2, 1 df = 8.0, P = .005). Thus, 27% of

Conclusion

To our knowledge, this is the first prospective study to directly compare outcomes in pleural infection with different chest tube sizes. The results demonstrate that in a large cohort of patients with pleural infection treated with a range of chest tube sizes and different insertion techniques, smaller-size tubes, 14F or smaller (mostly guide-wire inserted), cause much less pain than larger-size tubes (mostly blunt-dissection inserted), without impairing clinical outcome. Should these results

Acknowledgments

Author contributions: Dr Rahman: contributed to data collection, analysis, study design and concept, and manuscript preparation and approved the final manuscript.

Dr Maskell: contributed to data collection, study design and concept, and manuscript preparation and approved the final manuscript.

Dr C. W. H. Davies: contributed to data collection, study design, and manuscript preparation and approved the final manuscript.

Ms Hedley: contributed to data collection and manuscript preparation and

References (0)

Cited by (0)

Funding/support: The study was funded through a Medical Research Council grant [G9721289].

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestpubs.org/site/misc/reprints.xhtml).

View full text