CHEST TRAUMA (GENERAL)

Systematic review and meta-analysis of tube thoracostomy following traumatic chest injury; suction versus water seal.

Feenstra TM, Dickhoff C, Deunk J

Eur J Trauma Emerg Surg. 2018 Mar 15. Epub ahead of print

PURPOSE: Tube thoracostomy is frequently used in thoracic trauma patients. However, there is no consensus on whether low pressure suction or water seal is the optimal method of tube management. Against this background, we performed a systematic review of studies comparing suction and water seal management of chest tubes placed for traumatic chest injuries in adults. Evaluated outcomes are duration of chest tube treatment, length of stay in hospital, incidence of persistent air leak, clotted hemothorax, and the need for (re-)interventions.

METHODS: A systematic literature search according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines was performed. Included studies were evaluated according to the Cochrane Collaboration's tool for assessing the risk of bias, and according to Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines for assessing the quality of evidence.

RESULTS: After assessment of 120 identified studies, three RCT's (randomized controlled trials) were included in this review and meta-analysis. A favorable effect of suction was found for duration of chest tube treatment [MD (mean difference) - 3.38 days, P = 0.005], length of stay in hospital (MD -3.90 days, P = 0.0003), and the incidence of persistent air leak [OR (odds ratio) 0.27, P = 0.001]. No significant difference was found for the incidence of clotted hemothorax and (re-)interventions. The quality of evidence according to GRADE was low, except for persistent air leak (moderate).

CONCLUSIONS: Suction seems to have a positive effect on duration of chest tube treatment, length of stay in hospital and persistent air leakage in chest trauma. However, available data was limited and the quality of evidence was (very) low to moderate according to GRADE.

NEEDLE DECOMPRESSION / TENSION PNEUMOTHORAX

CHEST SEALS

Complications in Tube Thoracostomy: Systematic review and Meta-analysis.

Hernandez MC, El Khatib M, Prokop L, Zielinski MD, Aho JM.

J Trauma Acute Care Surg. 2018 Feb 14.Epub ahead of print 

BACKGROUND: Tube thoracostomy (TT) complications and their reported rates are highly variable (1-40%) and inconsistently classified. Consistent TT complication classification must be applied to compare reported literature to standardize TT placement. We aim to determine the overall TT related complication rates in patients receiving TT for traumatic indications utilizing uniform definitions.

METHOD: Systematic review and meta-analysis was performed assessing TT related complications. Comprehensive search of several databases (1975-2015) was conducted. We included studies that reported on bedside TT insertion (≥22 F) in trauma patients. Data were abstracted from eligible articles by independent reviewers with discrepancies reconciled by a third. Analyses were based on complication category subtypes: insertional, positional, removal, infection/immunologic/education and malfunction.

RESULTS: Database search resulted in 478 studies; after applying criteria 29 studies were analyzed representing 4981 TTs. Injury mechanisms included blunt 60% [49-71], stab 27% [17-34], and gunshot 13% [7.8-10]. Overall median complication rate was 19% (95% CI, 14 - 24.3). Complication subtypes included insertional (15.3%), positional (53.1%), removal (16.2%), infection/immunologic (14.8%), malfunction (0.6%). Complication rates did not change significantly over time for insertional, immunologic, or removal p=0.8. Over time, there was a decrease in infectious related TT complications as well as an increase in positional TT complications.

CONCLUSIONS: Generation of evidence based approaches to improve TT insertion outcomes is difficult as a variety of complication classifications have been utilized. This meta-analysis of complications after TT insertion in trauma patients suggests that complications have not changed over time remaining stable at 19% over the past three decades.

LEVEL OF EVIDENCE: III STUDY TYPE: Systematic review and meta-analysis.