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Is Routine Roentgenography Needed after Closed Tube Thoracostomy Removal?

Pacanowski, John P. MD; Waack, Matthew L. MD; Daley, Brian J. MD; Hunter, Karen S. MD; Clinton, Richard BS; Diamond, Daniel L. MD; Enderson, Blaine L. MD

Journal of Trauma-Injury Infection & Critical Care: April 2000 - Volume 48 - Issue 4 - pp 684-688
Article Titles

Background: Efficacy of chest radiograph protocol after tube thoracostomy tube (CT) removal.

Methods: Retrospective review (July of 1995 to July of 1996) of 141 patients with CT followed throughout their hospitalization. Excluded patients died (23 patients) or had thoracotomy (13 patients) before CT removal.

Results: A total of 105 patients had 113 CT removed (mean age, 36.9 years; Injury Severity Score = 23.4; CT duration, 5.0 days). Protocol chest radiographs were performed on average at 7.9 and 22.1 hours. Recurrent pneumothorax (RHPTX = new interpleural air) occurring in 12 patients (11%) and persistent pneumothorax (PHPTX = same volume of interpleural air) occurring in 13 patients (12%) caused no clinical problems and were treated without tube replacement. Three patients had symptoms after removal; none had RHPTX. Two patients had clinical signs; one reaccumulated a hemothorax requiring CT replacement, the other improved without replacement.

Conclusions: Clinically significant RHPTX/PHPTX after CT removal is infrequent. Signs not symptoms detect CT removal complications. At our institution, chest radiographs are obtained in a delayed manner from protocol and offer no benefit over clinical assessment.

Varied methods have been described for management of traumatic injuries resulting in hemothorax, pneumothorax, or both. 1–6 Commonly, a closed chest thoracostomy tube (CT) is placed to evacuate air, blood, or both, based on the patient’s signs, symptoms, or both, with clinical correlation of the radiographic findings. There are defined methods of estimating the size of pneumothoraces present on chest radiographs. 7–9 Most authors agree that pneumothorax greater than 20% require evacuation even in the absence of clinical symptoms or signs.

Just as there is controversy regarding CT placement, considerable variability exists in postplacement CT management, especially relative to their removal. Timing of tube removal depends on institutional methods for defining the resolution of traumatic hemothorax, pneumothorax (HPTX), or both. Although radiographic protocols after tube removal have not been well defined, some have recommended a chest radiograph between 12 and 24 hours after removal. 10

At our institution, chest radiographs (CXR) are obtained on a protocol to ensure that a pneumothorax is not present after tube removal. Cost containment measures focus on such routine clinical practices. The purpose of this study was to determine whether routine CXR after CT removal in traumatic HPTX offers any benefit over the clinical evaluation of respiratory status.

From the Division of Trauma and Critical Care, Department of Surgery (J.P.P., B.J.D., K.S.H., R.C., D.L.D., B.L.E.) and Department of Radiology (M.L.W.), The University of Tennessee Medical Center at Knoxville, Knoxville, Tennessee.

Address for reprints: Brian J. Daley, MD, Division of Trauma and Critical Care, Department of Surgery, The University of Tennessee Medical Center at Knoxville, Box U-11, 1924 Alcoa Highway, Knoxville, TN 37920; email:

Submitted for publication May 12, 1998.

Accepted for publication December 23, 1999.

Poster presentation at the 57th Annual Meeting of the American Association for the Surgery of Trauma, September 24–27, 1997, Waikoloa, Hawaii.

© 2000 Lippincott Williams & Wilkins, Inc.