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Background The optimal tube size for managing traumatic hemothorax, pneumothorax, or hemopneumothorax remains debated. While large-bore chest tubes (LCTs—≥ 28 Ch) are traditionally favored, emerging evidence suggests that small-caliber tubes (SCTs—≤ 14 Ch), such as pigtail catheters and small straight tubes, may offer similar efficacy with fewer complications. This study aimed to evaluate the comparative effectiveness and safety of SCTs versus LCTs from Randomized Controlled Trials (RCTs) in adult trauma patients and to assess the conclusiveness of the current evidence using trial sequential analysis (TSA). Methods The study was conducted according to the Cochrane recommendations, searching the PubMed, Scopus, and EMBASE datasets up to 25th March 2025 without language restrictions (PROSPERO ID: CRD420251023165). The primary outcome was treatment failure; secondary outcomes included insertion-related complications, duration of drainage, and length of hospital stay. Random effects models based on restricted maximum likelihood and Hartung-Knapp correction were developed. Sensitivity analysis was conducted to detect sources of heterogeneity. The risk of bias was assessed using the Cochrane RoB 2 tool. TSA was used to evaluate the risk of random error and to determine whether the required information size (RIS) had been reached. Results Four RCTs ( n  = 676 patients) were included. Pooled analysis showed no significant difference in failure rates between SCTs and LCTs (RR 0.95, 95% CI 0.66–1.35, I 2  = 0%). No significant differences were observed in complication rates or hospital stay. Duration of tube placement was significantly shorter in the SCT group (MD − 0.49 days, p  = 0.02). TSA indicated that the cumulative evidence was underpowered, achieving only 22% of the RIS (3110 patients). The Z-curve did not cross thresholds for benefit, harm, or futility. Conclusion SCTs appear to be as effective and safe as LCTs for selected trauma patients with uncomplicated thoracic injuries. However, due to limited sample size and heterogeneity across trials, current evidence is inconclusive. Larger, high-quality RCTs are warranted to confirm these findings and guide clinical practice.

The BTS pleural procedures audit collected data over a 2-month period in June and July 2011. In contrast with the 2010 audit, which focussed simply on chest drain insertions, data on all pleural aspirations and local anaesthetic thoracoscopy (LAT) was also collected. Ninety hospitals submitted data, covering a patient population of 33 million. Twenty-one per cent of centres ran a specialist pleural disease clinic, 71% had a nominated chest drain safety lead, and 20% had thoracic surgery on site. Additionally, one-third of centres had a physician-led LAT service.

Background Granieri and colleagues compared small-caliber chest drains (14 Ch or smaller) with large-bore chest tubes (28 Ch or larger) for traumatic hemothorax, hemopneumothorax, and pneumothorax and combined conventional meta-analysis with trial sequential analysis. Main points: While the pooled effect estimate suggested no clear difference in treatment failure, clinical translation requires caution. First, the randomized trials largely represent selected, stable thoracic trauma rather than high-risk phenotypes (for example, massive hemothorax, ventilated patients, or severe polytrauma). Second, the primary endpoint (“failure”) groups reinterventions that vary in clinical impact and are sensitive to local imaging and escalation thresholds (for example, second drain versus video-assisted surgery). Third, trial sequential analysis conclusions depend strongly on prespecified assumptions (baseline event rate and the smallest clinically important effect), which should be explicitly justified and, where possible, explored in sensitivity analyses. Conclusion These clarifications may reduce overgeneralization, better align conclusions with the included trial populations, and inform pragmatic multicenter trial design with standardized protocols and patient-centered outcomes.

The number of patients treated with direct oral anticoagulants is increasing worldwide. Although bleeding complications associated with direct oral anticoagulants are lower than those associated with vitamin K antagonists, the increased number of patients treated with these anticoagulants suggests that a higher absolute number of patients are at risk. Tube thoracostomy is an invasive procedure with a high risk of bleeding. To date, among direct oral anticoagulants, only dabigatran has a well-studied antidote to reverse its effects during emergency procedure or surgery. This report describes a case in which emergency placement of a tube thoracostomy, in a patient with type 2 respiratory failure due to left tension pneumothorax and receiving the anticoagulant rivaroxaban, in the pharmacokinetics phase with greater anticoagulant effect, did not result in bleeding greater than that typically encountered during such interventions. The procedure ended successfully with no acute complications.

Background Since the conception of enhanced recovery after surgery protocols, tubeless strategies have become popular. Herein, we introduce a previously unreported alternative air‐extraction strategy for patients who have undergone thoracoscopic wedge resection and explore its feasibility and safety. Methods Between January 2015 and June 2017, 264 consecutive patients underwent thoracoscopic wedge resection with different drainage strategies. Patients were divided according to the postoperative drainage strategies used: routine chest tube drainage (RT group), complete omission of chest tube drainage (OT group), and prophylactic air‐extraction catheter insertion procedure (PC group). Using the propensity score matching method, clinical parameters and objective operative qualities were compared among the three groups. Results Optimal 1:1 matching was used to form pairs of RT (n =36) and PC (n =36) groups and balance baseline characteristics among the three groups. The incidence rates of pneumothorax were 5.6% (2/36), 9.8% (5/51), and 19.4% (7/36) in the RT, OT, and PC groups, respectively (P = 0.07). Chest tube reinsertion incidence for postoperative pneumothorax was 19.4% (1/7) in the PC group and 60% (3/5) in the OT group. Other postoperative complications were comparable among these groups. Conclusions The prophylactic air‐extraction strategy may be an alternative procedure for selected patients. Remedial air extraction may reduce the occurrence of chest tube reinsertion for pneumothorax patients, but further investigation is required.

Purpose Since the introduction of vertebral body tethering (VBT) for adolescent idiopathic scoliosis (AIS), a variety of post-operative chest drainage systems have been utilized. Most surgeons use formal chest tubes with a Pleur-evac, while others use smaller bulb suction drains (e.g., Blake drain). In addition, some centers utilize pleural closure. This multicenter study evaluates whether drain type or pleural closure impact perioperative and 90 day complication rates. Methods A retrospective review was conducted from three institutions with established VBT programs. All preoperative, perioperative and 90 day postoperative data were analyzed to determine differences in outcomes between three cohorts: standard chest tube (SCT), standard chest tube with pleural closure (SCTPC) and 10 French Bulb drain (BD). Results 104 patients were identified for the study. 57 SCT, 25 SCTPC and 22 BD. All data are listed in order: SCT, SCTPC, BD. Length of stay (3.7, 4.3, 3.0 days) was less in the BD group ( p  = 0.009); post-operative drainage (460, 761, 485 cc) was less in the SCT and BD groups ( p  < 0.001); intra-operative estimated blood loss (EBL) 146, 382, 64 cc was less in the BD group ( p  < 0.001). No significant difference in number of days (3.2, 3.2, and 2.8 days) drainage was in place, groups ( p  = 0.311). Complication profile was similar with 2 chest tube reinsertions in the SCT and one hemothorax that resolved spontaneously in BD group. Conclusions In this series of 104 patients, SCT, SCTPC and BD all had a similar safety profile. All three methods were safe and effective in managing post-operative chest drainage after thoracic VBT. In the series, BD group had significantly shorter LOS than both groups that used chest tubes. Level of evidence Level III, Retrospective cohort study.

The Thopaz+ portable digital system was evaluated by the Medical Technologies Advisory Committee (MTAC) of the National Institute for Health and Care Excellence (NICE). The manufacturer, Medela, submitted a case for the adoption of Thopaz+ that was critiqued by Cedar, on behalf of NICE. Due to a lack of clinical evidence submitted by the manufacturer, Cedar carried out its own literature search. Clinical evidence showed that the use of Thopaz+ led to shorter drainage times, a shorter hospital stay, lower rates of chest drain re-insertion and higher patient satisfaction compared to conventional chest drainage when used in patients following pulmonary resection. One comparative study of the use of Thopaz+ in patients with spontaneous pneumothorax was identified and showed shorter drainage times and a shorter length of hospital stay compared to conventional drainage. No economic evidence was submitted by the manufacturer, but a simple decision tree model was included. The model was improved by Cedar and showed a cost saving of £111.33 per patient when Thopaz+ was used instead of conventional chest drainage in patients following pulmonary resection. Cedar also carried out a sub-group analysis of the use of Thopaz+ instead of conventional drainage in patients with pneumothorax where a cost saving of £550.90 was observed. The main cost driver for the model and sub-group analysis was length of stay. The sub-group analysis was based on a single comparative study. However, the MTAC received details of an unpublished audit of Thopaz+ which confirmed its efficacy in treating patients with pneumothorax. Thopaz+ received a positive recommendation in Medical Technologies Guidance 37.

A questionnaire was designed to measure junior doctors’ experience of performing practical procedures and was distributed to all junior doctors working in our emergency department during June 2005 and June 2006. The junior doctors were subjectively less experienced in all the procedures measured in 2006 compared to 2005. There were statistically significant reductions in experience of shoulder manipulation, suturing and wound exploration. Junior doctors are becoming less experienced in performing some practical procedures.

This study aimed to determine the most effective non-pharmacological intervention for pain relief following chest tube removal in adult patients. We performed a systematic review with network meta-analysis, searching electronic databases for randomized controlled trials up to January 20, 2024. Compared to control or placebo groups, the trials included adult patients receiving non-pharmacological interventions, such as cold therapy, relaxation exercises, music therapy, transcutaneous electrical nerve stimulation, or aromatherapy. Data analysis utilized a random-effects model, reporting standardized mean differences (SMD) with 95% confidence intervals (CI), and treatment ranking was determined through surface under the cumulative ranking analysis and forest plots. Sixteen studies enrolling 1,342 patients were included, with moderate to high heterogeneity. Cold therapy and relaxation exercises effectively reduced pain after chest tube removal, with SMD of −1.84 (95 % CI: −2.81 to −0.87) and −2.04 (95 % CI: −3.43 to −0.65), respectively, from baseline to immediately post-removal. From baseline to ten to twenty minutes after removal, both therapies continued to show significant pain reduction, with SMD of −1.96 (95 % CI: −3.14 to −0.77) for cold therapy and −2.01 (95 % CI: −3.75 to −0.28) for relaxation exercises. Sensitivity analysis supported these findings, and cold therapy’s efficacy appeared unaffected by obesity. However, publication bias, possibly due to small study samples, was noted. Cold therapy and relaxation exercises proved most effective for reducing pain immediately and up to ten to twenty minutes after chest tube removal. Given their cost-effectiveness, lack of side effects, and ease of use, we recommend relaxation exercises as a practical alternative to cold therapy. Nonetheless, further studies are needed to comprehensively assess non-pharmacological options for managing chest tube removal pain. Incorporate cold therapy and relaxation exercises into post-chest tube removal pain management to improve patient comfort and minimize reliance on pharmacological interventions.

Primary spontaneous pneumothorax occurs in otherwise healthy young patients. Optimal management is not defined and often results in prolonged hospitalisation. Data on efficacy of ambulatory options are poor. We aimed to describe the duration of hospitalisation and safety of ambulatory management compared with standard care. In this open-label, randomised controlled trial, adults (aged 16–55 years) with symptomatic primary spontaneous pneumothorax were recruited from 24 UK hospitals during a period of 3 years. Patients were randomly assigned (1:1) to treatment with either an ambulatory device or standard guideline-based management (aspiration, standard chest tube insertion, or both). The primary outcome was total length of hospital stay including re-admission up to 30 days after randomisation. Patients with available data were included in the primary analysis and all assigned patients were included in the safety analysis. The trial was prospectively registered with the International Standard Randomised Clinical Trials Number, ISRCTN79151659. Of 776 patients screened between July, 2015, and March, 2019, 236 (30%) were randomly assigned to ambulatory care (n=117) and standard care (n=119). At day 30, the median hospitalisation was significantly shorter in the 114 patients with available data who received ambulatory treatment (0 days [IQR 0–3]) than in the 113 with available data who received standard care (4 days [IQR 0–8]; p<0·0001; median difference 2 days [95% CI 1–3]). 110 (47%) of 236 patients had adverse events, including 64 (55%) of 117 patients in the ambulatory care arm and 46 (39%) of 119 in the standard care arm. All 14 serious adverse events occurred in patients who received ambulatory care, eight (57%) of which were related to the intervention, including an enlarging pneumothorax, asymptomatic pulmonary oedema, and the device malfunctioning, leaking, or dislodging. Ambulatory management of primary spontaneous pneumothorax significantly reduced the duration of hospitalisation including re-admissions in the first 30 days, but at the expense of increased adverse events. This data suggests that primary spontaneous pneumothorax can be managed for outpatients, using ambulatory devices in those who require intervention. UK National Institute for Health Research.