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.

Methods

After institutional review board approval was obtained, a retrospective chart review was conducted of all general surgical inpatients with a chest tube in place after a thoracic procedure using International Classification of Diseases, 9th Edition (Centers for Disease Control and Prevention, National Center for Health Statistics, 1979) codes between January 1, 2010 and December 31, 2012 (Box).

Patients who had cardiac surgery were excluded. Cardiac surgical patients were excluded because their chest tubes are most often mediastinal and it is not possible to tell from the medical record if the mediastinum communicated with the pleural spaces or not. Cardiac surgical patients were also excluded because they differ significantly from general surgical patients in postoperative complications. The electronic medical record was reviewed to acquire demographic data; location, size, date, and time of chest tube insertion and removal; vital signs including respiratory rate and pulse oximetry before chest tube removal and at 4 hours and 12 hours after removal; and chest radiographs before and after chest tube removal. We used the official radiology report in lieu of reviewing films.

The most recent chest film done before chest tube removal was compared with the postremoval film to identify any changes. In the circumstance that a patient had more than one thoracic procedure during this timeframe, we used data from the first chest tube placement. For patients with more than one chest tube in place simultaneously, the last chest tube removal was used for data analysis. Our standard was a chest radiograph immediately after chest tube removal, and most patients in this cohort had their film taken within 2 hours after chest tube removal. A clinically significant change in physiology or film findings was considered to be one that was either documented or led to a change in management. A clinically significant change was a change in vital signs or oxygen saturation that was recognized and noted by a clinician. In addition, new findings noted on the radiology report were also considered clinically significant if they would typically be associated with a change in clinical status. The data were then entered into a Red Cap database for analysis (Vanderbilt University, Nashville, TN).

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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

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

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