This study supports the general consensus in the literature that a postremoval chest radiograph is not indicated after removal of a chest tube in most pediatric patients. There may be some patients for whom a chest radiograph is indicated if there is clinical concern for pneumothorax or reaccumulation of pleural fluid. Our study showed that only 2 out of 281 patients had a clinically significant event after chest tube removal, and the postremoval film did not identify the problem. It was clinical symptoms that prompted repeat chest radiography. Based on the findings of this study, we have changed our practice guidelines to not obtain a chest radiograph after removal of a chest tube unless there is increased pain, respiratory symptoms, or clinical concern. Ultimately, we expect that we will further define more specific criteria for indication for chest radiographs in the postoperative period. This is supported by French et al. (2016)), who describe the need to develop chest tube management pathways (French et al., 2016).
"We have changed our practice guidelines to not obtain a chest radiograph after removal of a chest tube unless there is increased pain, respiratory symptoms, or clinical concern."
Based on the findings of this study, we identified 18 of 281 (6.4%) patients who had any change in chest radiograph after removal of the chest tube. Only two patients (0.7%) had clinically significant symptoms requiring intervention (reintubation and chest tube replacement), both of whom had benign initial postremoval radiography results. Based on these data, the general surgery team at Boston Children's Hospital implemented a practice change, effective January 1, 2016, to limit routine chest radiography after removal of a chest tube to patients with any change in respiratory status, any other clinical concern, or provider/surgeon request.
Omitting postremoval chest radiography as a change in practice will provide significant cost savings and reduce exposure to radiation in pediatric patients. An additional benefit is reducing pain and discomfort associated with a chest radiograph. There were 170 patients who had a single-view chest radiograph at a cost of $254, and 111 patients who underwent two-view chest radiographs at a cost of $448. Eliminating this practice will lead to elimination of 281 chest radiographs, with a total estimated savings of $92,908 over a 3-year timeframe, or $30,969 per year.
The acute care pediatric nurse practitioner provides care in the inpatient settings, helping to manage care for postoperative surgical patients. Often, the acute care pediatric nurse practitioner is the provider removing the chest tube, deciding when a chest radiograph is indicated, and reviewing the chest radiograph, so this information will help guide inpatient pediatric nurse practitioner providers. These data will contribute to the reduction in the number of chest radiographs for pediatric patients, contributing to the overall wellness of these young patients.
Further research is indicated, and our future plans include a follow-up study to assess the effect of this clinical practice change on patient outcome. This would contribute to the evidence supporting the clinicians' decision making about which patients may need consideration for chest radiography after removal of a chest tube.
This was a retrospective chart review conducted at a single tertiary academic pediatric health care system. Retrospective charts reviews have the inherent limitation of missing data. Although we have a standard practice for removing chest tubes, there are many practitioners, so there is a possible variation in technique that may be a factor associated with the development of pneumothoraces that cannot be measured with this type of study. Additionally, there was inconsistent documentation identifying which provider removed the chest tube, therefore, this factor cannot be assessed.
J Pediatr Health Care. 2017;31(5):588-593. © 2017 Mosby, Inc.