Percutaneous pleural pigtail catheter placement is an indispensable skill for providers caring for critically ill infants, allowing for the evacuation of pleural fluid and pneumothoraces. Competence in tube thoracostomy is required to successfully complete neonatology, pediatric critical care, emergency medicine, and surgical training. Commercially available trainers are available to mimic placement of a surgically placed chest tube in adult and school-aged pediatric patients.1–4 Published costs for these trainers range from $1800 to S2200, independent of the need to order replacement parts over time. These costs can be prohibitive for training programs, especially in resource-poor countries. Furthermore, there are no realistic simulation models commercially available for trainees to practice and learn chest tube placement on infants, particularly for learners desiring to learn pleural pigtail placement via the Seldinger technique.
Prior cadaver models,5 animal-based models6–8 and nonanimal training models9–11 have been described to simulate the placement of a traditional surgical chest tube, with most of these designed for placement in adult patients. However, none of these have been designed for teaching placement of a pigtail catheter via the Seldinger technique. Additionally, none of the published models allow for simulation of evacuation of a pleural effusion.
Our objective was to develop an inexpensive and reproducible infant pleural pigtail trainer (IPPT) to help faculty teach infant percutaneous pleural pigtail placement to physician trainees, nurse practitioners, and physician assistants caring for critically ill infants. We aimed to develop and validate a model that was easy to use, felt realistic, and could be used by multiple learners without having to buy or replace expensive or perishable materials. Access to an affordable and accessible trainer could also help bedside nurses understand the steps of pigtail placement so they can be better prepared to provide necessary assistance during the procedure.
What This Study Adds
- An effective model for pleural pigtail placement can be inexpensively constructed using discarded bags of intravenous fluid and easy-to-find hardware materials.
- Future studies are needed to assess whether this model helps training providers and nurses develop and maintain the clinical skills for successful percutaneous pleural pigtail catheter placement.
Infant Pleural Pigtail Trainer
Using the Seldinger technique for placement of a pleural pigtail catheter involves inserting a needle superior to a rib into the desired intercostal space and advancing the needle until pleural fluid is aspirated. A flexible wire is then placed through the needle and the needle is removed. After dilating the subcutaneous tissue around the wire insertion site with a tissue dilator, the pigtail catheter is placed over the wire into the pleural space and the wire is removed. The catheter is then sutured in place to allow continued drainage of the pleural fluid. Development of the IPPT required careful attention to ensure that all steps of the procedure could be performed. The IPPT was primarily developed by an experienced board-certified pediatric critical care physician and simulation technician. The body of the trainer was composed of a discarded Sani Baby (Simulaids, Product Number 100-2121, Saugerties, New York) infant cardiopulmonary resuscitation (CPR) manikin.
The internal airway components of the manikin were removed to allow placement of the fluid bags. The plastic sides of the manikin were trimmed away on both sides using heavy scissors to allow catheter placement at the mid-axillary line. The rib cage was constructed using 14-gauge electrical cable wires held together by medical adhesive tape. Discarded 250-mL bags of intravenous fluids were placed inside the chest cavity to simulate pleural fluid. Different fluid containers were tested, but the 250-mL bags of saline were found to be not only ideally sized to fit inside the chest cavity, but also to be made out of durable plastic material that was able to partially seal over the wire so that the fluid did not drain out of the bag between the dilation step and the placement of the catheter (Figure 1).
To add realism to the procedure, red food coloring was added to the fluid using a syringe prior to placement of the bag inside the chest cavity. The existing skin layer of the manikin was removed and shelf liner (Con-Tact Brand Solid Grip Premium Non-Adhesive Non-Slip Shelf and Drawer Liner; 18 inches × 4 ft, Taupe) was wrapped around the chest and abdomen of the infant model to simulate the skin layer, with holes and nipples marked with a permanent marker at the fourth intercostal space (Figure 2). Small holes were cut into the shelf liner to allow securement to the existing pegs on the manikin body. The developers ensured that the ribs and intercostal spaces could be palpated through the shelf liner “skin.”
Survey and Rating Procedure
Pediatric critical care faculty used the IPPT to simulate placement of an 8.5F, 15-cm Fuhrman drainage catheter (Cook Medical, Order number G55723) into the pleural space via Seldinger technique (Figure 3). After completing the procedure on the manikin, the faculty rated their experiences using the IPPT on a survey. The survey utilized three 5-point Likert scale items to score the IPPT for realism and utility for teaching. For analysis, answers marked as “Agree” or “Strongly Agree” were grouped into an affirmative answer, creating a dichotomous scale. (See Supplemental Digital Content 2, the Faculty Survey, available at http://links.lww.com/ANC/A56.)
Seven pediatric critical care faculty tested the IPPT. All faculty agreed that the IPPT provided a realistic simulated reproduction of placing a pleural pigtail. All faculty felt that the IPPT was simple to use and expressed that they would use it in the future to teach this skill to trainees.
The cost to assemble the model was about $15. Broken into the different components, the CPR manikin was free (discarded by our simulation center), the shelf lining was $5.59 and the wires were $9.68. The wires could be reused indefinitely. Each roll of shelf lining was found to be useful for about 15 “skins,” although these could each be used multiple times before needing to be replaced. Discarded and expired bags of intravenous fluids were obtained for free from our pharmacy. Seeing as not all centers may have a discarded CPR manikin available, the manikin is available from the manufacturer for $126.80, thus potentially bringing costs up to a total of $142.07.
We have developed and validated an inexpensive and reproducible trainer for neonatal pigtail catheter placement and pleural fluid removal using the Seldinger technique. This trainer can be used to teach providers of all different professions, including physician trainees, nurse practitioners, and physician assistants, how to perform a potentially life-saving procedure for infants with pleural effusions. The trainer can also be used to help bedside nurses better understand the steps required in the procedure so they can be better prepared to assist providers during the procedure and anticipate next steps and potential complications. Commercially available nonanimal chest tube trainers exist but are expensive and designed for placement of surgical chest tubes. Very few commercially available pediatric models exist and infant-sized models are not available.
Prior studies have described development and validation of different types of chest tube trainers. Cadaver models5 and animal-based models6–8 can be costly and difficult to maintain fresh, with the added infectious risk of handling raw meat. Both published nonanimal pediatric chest tube trainers were designed for teaching placement of surgical chest tubes, and neither is able to simulate the evacuation of a pleural effusion.10,11 Given the cost and potential refrigeration needs associated with nonanimal models, cadaver models, and animal-based models, the IPPT may have the most impact in resource-poor settings, including in developing countries, where lack of financial resources and unreliable access to electricity may limit the ability to use other models.
Development of a model for fluid removal via the Seldinger technique is complicated, because of the multiple steps involved and the need for a sealed fluid container that is durable enough to tolerate puncture with a needle, dilation, and placement of a catheter while still retaining enough elasticity so it does not rupture. The investigators tried using other containers, including commercially available plastic snack bags and medical gloves; however, the 250-mL bags of saline and Lactated Ringers offered the best balance of necessary size, easy availability, and durability.
Needle decompression of tension pneumothoraces is another important life-saving neonatal procedure. While the IPPT was not validated for this procedure, modification of the model by removing approximately 100 mL of fluid from the IV fluid bags and replacing it with air allowed for realistic simulation of needle decompression of a pneumothorax during a subsequent simulation-based training exercise. Participants were excited to experience the “whoosh” often described when decompressing a tension pneumothorax. Further evaluation of this modification would be required to validate the IPPT for teaching evacuation of tension pneumothoraces.
Improvements and Limitations
Although this low-cost and reproducible IPPT has been validated by pediatric critical care experts for realism and ease of use, further studies will be needed to assess its impact on provider and bedside nurse training, including its impact on their acquisition of skills transferrable to the clinical setting.
An effective model for infant pleural pigtail placement can be inexpensively constructed using discarded bags of intravenous fluid, an easily available infant CPR manikin, and easy-to-find hardware materials. Future studies need to be performed to assess whether use of this trainer helps bedside providers and nurses develop and maintain the clinical skills necessary for successful percutaneous pleural pigtail catheter placement.
1. Simulab Corporation. TraumaChild Pediatric Surgical Simulator. https://www.simulab.com/products/traumachild-pediatric-surgical-simulator
. Accessed April 5, 2019.
3. SynDaver Labs. Wearable Chest Tube Trainer. http://syndaver.com/shop/synatomy/chest-tube-trainer-2/
. Accessed April 4, 2019.
5. Proano L, Jagminas L, Homan CS, Reinert S. Evaluation of a teaching laboratory using a cadaver model for tube thoracostomy
. J Emerg Med. 2002;23(1):89–95.
6. Ballard HO, Shook LA, Iocono J, Turner MD, Marino S, Bernard PA. Novel animal model for teaching chest tube placement. J Ky Med Assoc. 2009;107(6):219–221.
7. Naicker TR, Hughes EA, McLeod DT. Validation of a novel resin-porcine thorax model for chest drain insertion training. Clin Med (Northfield Il). 2012;12(1):49–52.
8. Tatli O, Turkmen S, Imamoglu M, et al. A novel method for improving chest tube insertion skills among medical interns: using biomaterial-covered mannequin. Saudi Med J. 2017;38(10):1007–1012.
9. Hutton IA, Kenealy H, Wong C. Using simulation models to teach junior doctors how to insert chest tubes: a brief and effective teaching module. Intern Med J. 2008;38:887–891.
10. Gupta AO, Ramasethu J. An innovative nonanimal simulation trainer for chest tube insertion in neonates. Pediatrics. 2014;134:e798–e805.
11. Al-Qadhi SA, Pirie JR, Constas N, Corrin MSC, Ali M. An innovative pediatric chest tube insertion task trainer simulation: a technical report and pilot study. Simul Healthc. 2014;9:319–324.