Pigtail Catheter

Pigtails This week I had the pleasure of working with my dear colleagues during the Pediatric Procedure Course at ACEP/AAP Advanced Pediatric Assembly.  We covered numerous important procedures, but one that deserves mentioning here is the use of Pigtail Catheters for pneumothorax and pleural fluid drainage. We have previous discussed the value of Pigtail Catheters for the treatment of Spontaneous Pneumothorax and Traumatic Pneumothorax.  Obviously, every decision we make comes with risks and benefits as well as pros and cons.  The choice of a device to drain air or fluid from the pleural cavity certainly shouldn’t be a snap decision.

Large Caliber vs Small Caliber

Large Caliber Chest Tubes

  • Pros
    • Can drain VISCOUS fluid
    • Resist becoming obstructed or kinked.
  • Cons
    • Occupy large space in the child’s narrow intercostal space.
    • Potential risk for damage to chest wall structures (neurovascular bundle, muscles, etc).
    • Difficult for patient to be mobile with while it is inserted.

Small Caliber Pigtail Catheters

  • Pros
    • Shown to lead to less discomfort.
    • Less hindrance to ambulation and mobility.
    • Proven to be as effective as larger bore chest tubes.
    • Can lead to shorter hospital days.
  • Cons
    • Can be mechanically kinked.
    • Can be occluded by viscous or turbid fluid.

Open vs Seldinger

Open Technique for Large Caliber Chest Tubes

  • Pros
    • Able to clearly define that you are in the appropriate location.
      • You can feel the lung parenchyma and know that you aren’t inserting tube into the liver or spleen!
    • Relatively straight forward procedure.
  • Cons
    • More invasive.
    • More traumatic.
    • More painful.
    • Produces larger scars.

Seldinger Technique for Small Caliber Pigtail Catheters

  • Pros
    • Less Invasive.
    • Less traumatic.
    • Less likely to damage surrounding structures.
    • Smaller region involved and pain can be more reasonably controlled.
    • Less scarring.
  • Cons
    • Seldinger technique doesn’t allow for easy confirmation of appropriate placement.
      • Some reports of organ laceration.
    • More steps to the procedure.
    • Requires more specialized equipment.

Reasonable Recommendation

  1. Consider what it is that you need to drain.
    1. If it is air or acute blood, use a pigtail.
    2. If it is expected to be viscous, consider a small caliber thoracostomy tube.
      1. One study actually showed that empyema can successfully be drained by pigtail catheter and recommends starting with pigtail first.
    3. If considering a traditional thoracostomy tube… reconsider it… and reconsider it again… Pigtail likely will be better.
  2. Use Ultrasound!
    1. Improve your vision and define your anatomy with ultrasound.
    2. There is no reason to guess!
    3. Reduce complications by paying attention to anatomic landmarks.
  3. Aim High!
    • Some experts advocate for inserting Pigtail Catheters above the 6th intercostal space to avoid subdiaphragmatic catheter placement.
  4. Be Safe!
    • Use a J-tipped (flexible tipped) guidewire with your Pigtail Catheter, rather than a straight wire.
  5. Don’t Be Cruel!
    • Consider the advantages of having the patient more comfortable and able to ambulate earlier.

     

References

Kulvatunyou N1, Erickson L, Vijayasekaran A, Gries L, Joseph B, Friese RF, O’Keeffe T, Tang AL, Wynne JL, Rhee P. Randomized clinical trial of pigtail catheter versus chest tube in injured patients with uncomplicated traumatic pneumothorax. Br J Surg. 2014 Jan;101(2):17-22. PMID: 24375295. [PubMed] [Read by QxMD]

Kuo HC1, Lin YJ, Huang CF, Chien SJ, Lin IC, Lo MH, Liang CD. Small-bore pigtail catheters for the treatment of primary spontaneous pneumothorax in young adolescents. Emerg Med J. 2013 Mar;30(3):e17. PMID: 22523033. [PubMed] [Read by QxMD]

Lin CH1, Lin WC, Chang JS. Comparison of pigtail catheter with chest tube for drainage of parapneumonic effusion in children. Pediatr Neonatol. 2011 Dec;52(6):337-41. PMID: 22192262. [PubMed] [Read by QxMD]

Liu CM1, Hang LW, Chen WK, Hsia TC, Hsu WH. Pigtail tube drainage in the treatment of spontaneous pneumothorax. Am J Emerg Med. 2003 May;21(3):241-4. PMID: 12811722. [PubMed] [Read by QxMD]

Dull KE1, 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. PMID: 12187131. [PubMed] [Read by QxMD]

Roberts JS1, Bratton SL, Brogan TV. Efficacy and complications of percutaneous pigtail catheters for thoracostomy in pediatric patients. Chest. 1998 Oct;114(4):1116-21. PMID: 9792586. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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