Is a Chest Radiograph Required After Removal of Chest Tubes in Children?

Ellen McGrath, PNP; Lee Ranstrom, PNP; Debra Lajoie, PhD, RN; Lauren McGlynn, PNP; David Mooney, MD, MPH

J Pediatr Health Care. 2017;31(5):588-593.

Abstract and Introduction

Abstract

Our objective was to determine the clinical value of obtaining a chest radiograph after removal of a chest tube. We conducted a retrospective chart review of pediatric general surgical patients with a chest tube in place after a thoracic procedure over a 3-year time period. Postremoval films were considered to be of value if they led to a change in clinical management. Of 468 patients who had a thoracic procedure, 281 patients had a chest tube and a postremoval film. In 263 patients (93.6%) there was no change in the postremoval film result compared with baseline. Only two patients (0.7%) required an intervention based on symptoms, not based on the postremoval film. Eliminating routine postremoval radiographs after chest tube removal in pediatric patients will lessen radiation exposure and provide cost savings with no adverse impact on outcome.

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Table 1. Literature review
Study	Sample	Study design	Findings	Recommendations
Anand et al., 2012	N = 67Adults on trauma service	Retrospective chart review	Chest wall thickness is an independent risk factor for the development of PPP.	Significant pneumothoraces should be clinically apparent in the form of patient signs and symptoms, which will then prompt radiographic evaluation.
Cunningham et al., 2014	N = 462Pediatric patientsCardiac patients excluded	Retrospective chart review	In noncardiac patients with a CT, tube reinsertion is uncommon, and tube replacement is secondary to symptoms.	Routine post-CT removal CXR is not necessary. CXR in these patients should be obtained based on clinical indications after CT removal.
Goodman et al., 2010	N = 608 adult trauma patients	Retrospective chart review	The selective omission of CXR after chest tube removal in less severely injured, nonventilated patients does not adversely affect outcomes or increase reintervention rates.	Omission of routine CXR after chest tube removal in selected patients decreases hospital charges without compromising patient safety or clinical outcomes.
McCormick et al., 2002	N = 1,000 patients with median sternotomy for coronary artery bypass graft or valve operation	Chart review	There was a 1.5% incidence of therapeutic intervention after chest tube removal.	Omission of routine postoperative chest tube removal CXR is safe, and removal of chest tubes in postoperative cardiac patients is not an indication for CXRs.
Pacharn et al, 2002	N = 374 pediatric cardiac surgery patients	Retrospective chart review	13.6% had a radiographically defined PTX within 6 hours after thoracostomy tube removal. Symptoms present before CXR was done.	Clinical signs and symptoms identified nearly all patients with significant pneumothoraces.
Sepehripour et al., 2012	N = 6 best evidence studies (Level 3)	Literature review	Routine post–drain removal CXR provides no diagnostic or therapeutic advantage over clinically indicated CXR or simple clinical assessment.	Omission of routine post–drain removal CXRs in patients after cardiothoracic surgery is safe, and CXRs should be performed only when clinically indicated.
Stather et al., 2011	N = 93 patients ages 18 years and younger (included cardiac surgery patients)	Prospective audit, 6-month period	Four patients (4.2%) had a pneumothorax after chest drain removal, one patient required insertion of a further chest drain for pneumothorax, and one patient required an additional drain because of recurrent pleural effusion. Three resolved spontaneously. All patients who had postprocedure pneumothorax were younger than 1 year of age; three had had cardiac surgery, and one had an empyema.	Through ensuring that simple safety measures are in place and staff are well trained in chest drain removal, the number of cases of pneumothorax can be significantly reduced, decreasing both the length of hospital stay and the need for further invasive interventions.
van den Boom and Battin, 2007	N = 100 infants	Retrospective chart review (1998–2004)	In asymptomatic infants, routine CXR showed some reaccumulation of air—reinsertion not required. In the 12 clinically symptomatic infants, chest tubes were reinserted in five.	Close observation is likely to detect clinically relevant recurrence of pneumothorax.
Whitehouse et al., 2009	N = 68 adult thoracic surgery patients		5% had a change in management made on basis of clinical status, not CXR.	It is not necessary to perform routine chest radiography in thoracic surgery patients after postoperative thoracostomy tube removal. It would be better to monitor these patients clinically and request CXR only on the basis of deterioration in clinical findings.

Note. CT, chest tube; CXR, chest x-ray; PPP, post pull pneumothorax; PTX, pneumothorax.

Table 2. Sample demographics
Variable	Range	Mean	Percentage
Age	1 day to 30 years	7.5 years
Length of stay	2–685 days	27.5 days
CT duration	1–81 days	7.2 days
CT indication
Surgery/VATS			85.8
Spontaneous pneumothorax			8.9
Pleural effusion			2.5
Traumatic pneumothorax			1.1
Empyema			0.4
Other			0.6
Location CT placed
Operating room			94.3
Emergency department			1.8
Radiology			3.2
Surgical unit			0.4
Type of CT
Thoracotomy drain			73.9
Blake drain			18.6
Pigtail			7.5

Note. CT, chest tube; VATS, video-assisted thoracoscopic surgery.

Table 3. Comparison of EA to non-EA patients
Characteristic	EA Patients64	Non-EA Patients217	p
Age, years	0.8 (0.3–1.6)	10.0 (1.6–16.4)	<.001
Sex, male	30 (47)	133 (61)	.040
Length of stay, days	61 (23–119)	5 (3–8)	<.001
CT duration, days	10 (7–18)	3 (2–5)	<.001
Location of CT placed
Operating room	64 (100.0)	201 (92.6)	.19
Emergency department	0 (0.0)	5 (2.3)
Radiology	0 (0.0)	9 (4.1)
Surgical unit	0 (0.0)	2 (0.9)
Type of CT			.10
Pigtail	2 (3.2)	19 (8.8)
Thoracotomy tube	53 (82.8)	154 (71.0)
Blake drain	9 (14.0)	44 (20.3)

Note. CT, chest tube; EA, esophageal atresia.
N = 281. Data are reported as median (interquartile range) or frequency (percentage).

Box. *International Classification of Diseases, 9th Edition* (ICD-9) procedure codes
32601 through 32674 inclusive, 32096 through 32150 inclusive, 32440, 32480, 32482, 32484, 32505, 32506, 32507, Spontaneous pneumothorax procedure codes: 32550, 32551, 32554, 32556, 32557, 32999