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. 

In This Article

Literature Review

There is growing evidence in the peer-reviewed literature that chest radiographs are not routinely indicated after removal of chest tubes in pediatric and adult patients (Goodman et al., 2010, McCormick et al., 2002, Palesty et al., 2000, Sepehripour et al., 2012, Whitehouse et al., 2009). Several articles suggested that close monitoring of respiratory status and clinical symptoms would identify nearly all patients with significant pneumothoraces (Cunningham et al., 2014, van den Boom and Battin, 2007).

Although three studies suggested that selective chest radiography should be based on the provider's good clinical judgment in combination with the patient's respiratory symptoms (Anand et al., 2012, Pacharn et al., 2002; van den Boom & Battin, 2007), limited evidence was found specific to the pediatric population (Pacharn et al., 2002, Stather, Cheshire, Bogwandas, & Peek, 2011).

A study with Level 3 evidence in cardiothoracic surgery patients found that clinically significant changes were detected on 2% to 40% of routine postremoval films, versus 79% of clinically indicated chest films, and that clinical symptoms are a positive predictor of major reintervention (Sepehripour et al., 2012). A retrospective study of 374 pediatric cardiac surgery patients found that 13.6% of patients had a visible pneumothorax on postremoval chest films and that clinical signs or symptoms identified those patients with pneumothoraces that required major intervention (Anand et al., 2012, Pacharn et al., 2002). A large retrospective study of noncardiac pediatric patients (N = 462) compared patients with or without a postremoval film concluded that development of a pneumothorax after chest tube removal was rare and that routine chest radiography after chest tube removal does not provide clinically relevant information (Cunningham et al., 2014).

Chest wall thickness was found to be an independent risk factor for the development of a pneumothorax after chest tube removal. A study of 100 infants concluded that clinical observation was sufficient to identify recurrent pneumothoraces (van den Boom & Battin, 2007). Stather (2011) found an incidence of pneumothorax of 4.2% after chest tube removal in a cohort of 95 pediatric patients. Omitting a postremoval film in low-risk trauma patients was not associated with an increase in reinsertion rates and provided a 3-year savings of $48,840 (Goodman et al., 2010).

In reviewing the existing literature, we did not believe that the pediatric data were compelling enough to warrant eliminating a chest radiograph (Table 1).