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A 2-year-old girl is admitted to the paediatric critical care unit following a traumatic pneumothorax as a result of a road traffic collision. After a few days, the chest drain is removed, and she is transferred to the ward for further observation. You clerk the patient on admission to the paediatric ward and are pleased to note that she is well, with no signs of respiratory distress and all observations within normal limits for her age. A senior colleague requests that you arrange a chest X-ray (CXR) to ensure that the pneumothorax has resolved. You question the importance of this investigation in an asymptomatic child.
Structured clinical question
Following chest drain removal in children (patient), does routine chest radiography (intervention) assist in monitoring or change the management of asymptomatic patients (outcome)?
In December 2019, we searched Embase (1946–present) and MEDLINE (1946–present) databases using the OVID search interface. Our search terms included: (chest x-ray OR chest radiograph) AND (chest drain OR chest tube OR thoracostomy tube) AND (removal OR withdrawal) AND (children OR paediatrics OR adolescents OR infants). We identified 98 articles, written in English language, which were reviewed further; case reports and conference abstracts were excluded. A further search of the Cochrane Library was performed using the same search terms, which identified 14 clinical trials; however, none of these trials were appropriate for our clinical question. A total of 6 relevant studies were identified as described in table 1. The level of evidence was classified according to Oxford Centre for Evidence-Based Medicine 2009.1
Chest drain insertion is common for the treatment of pneumothoraces, pleural effusions, empyema and in postoperative care following cardiothoracic surgery. During subsequent removal, it is possible for air or fluid to accumulate in the pleural space leading to recurrence. Other complications can include bleeding, infection and retained foreign body fragments.2 Currently, as part of routine practice in many institutions, a CXR is performed after removal of the drain in order to assess for resolution and exclude complications. However, in the majority of cases, these adverse effects present clinically with signs and symptoms of respiratory compromise. Therefore, the need for routine chest radiography warrants evaluation of its risk–benefit profile.
All of the studies identified in the search agreed with the general consensus that following chest drain removal, close clinical observation of respiratory function, signs and symptoms is favourable over routine chest radiography and that the management of patients, after chest drain removal, does not change based on the result of routine chest radiography.2–7 This is also in keeping with the adult literature.8 9 Collectively the studies support the following:
Risk of pneumothorax after chest drain removal is low.
Clinical findings predict the need for intervention.
Where reaccumulation is shown on CXR, intervention is rarely required.
Postremoval radiography is frequently normal even in those that go onto require intervention.
Pacharn et al 2 identified that clinical findings predicted the need for intervention, suggesting that chest imaging may be unnecessary in asymptomatic patients. In this study, all patients with symptoms suggestive of pneumothorax (86%) presented prior to radiography highlighting that the CXR results did not alter management decisions. These findings are corroborated by van den Boom and Battin,3 who discovered that out of 35 asymptomatic neonates, nine patients (26%) showed reaccumulation of their pneumothorax on postremoval imaging, of which none required additional management. These authors concluded that clinical observation only is adequate to detect recurrent pneumothorax in infants. These findings may be limited methodologically by the use of retrospective chart reviews due to missing data, inconsistent recording of data and the inevitable variation in healthcare practice. Both studies were also restricted to single centre tertiary units.
Woodward et al 4 calculated the rate of any pneumothorax after chest drain removal as 1.7% and reasoned that as the risk is low, it may be safe to reserve chest radiography for symptomatic patients only. In this study, there were 60 episodes of chest drain removal and no episodes of significant pneumothoraces; all children were asymptomatic highlighting that routine CXR was not appropriate. However, their findings may be limited due to a small sample size, inclusion of cardiac surgery patients only and/or variation in their removal techniques. McGrath et al 5 identified that only 0.7% of paediatric general surgery patients had significant symptoms requiring intervention after chest drain removal. Remarkably, this was not seen on postremoval radiography, and instead clinical symptoms prompted repeat investigations and additional management. Again, these authors have supported the overall agreement that routine imaging after removal of chest drains may be inappropriate unless clinically indicated and have implemented change to their practice guidelines.
Cunningham et al 6 found that out of 28 (8.6%) patients who were found to have pneumothorax on postremoval imaging, only three patients required chest tube reinsertion, of which 71% had coexisting signs and symptoms suggestive of pneumothorax. Additionally, one patient (0.7%), who did not have postremoval imaging, developed significant symptoms requiring reinsertion of the chest drain.
Furthermore, these findings are supported by Whitehouse et al,7 who identified that out of 25 patients who had chest radiography after removal, only one (4%) required additional intervention. In this study, 66% of patients did not undergo postremoval radiography and did not experience any adverse effects highlighting that routine radiography may not be necessary. Therefore, these authors have stated that chest radiographs should be used based on clinical indication as an adjunct to signs and symptoms. This study included both adult and paediatric patients.
The reason to evaluate the necessity of radiography following chest drain removal is multifactorial. Considering patient safety, it is important to limit radiation exposure in paediatric patients. Although plain film radiographs carry a significantly lower risk than computerised tomography (CT) imaging, increased exposure nonetheless correlates with an increased risk of malignancy in children, particularly leukaemia, thyroid and breast cancer.10 Therefore, it is essential that we are certain the benefits outweigh the risks in routine use of radiographic investigations. Furthermore, radiography may be uncomfortable, upsetting and in some instances painful for children. This may be as a result of fear, anxiety and uncertainty in the healthcare environment, which may precipitate negative experiences and future avoidance behaviours.11 Finally, routine radiographs are costly in the current economic climate and increasing need for financially prudent healthcare. McGrath et al 5 calculated a total estimated savings of US$30 969 per year at a single tertiary centre in Boston.
In conclusion, routine CXR following chest drain removal in children is unlikely to change the management of asymptomatic patients. However, in symptomatic patients, chest imaging should be considered as an adjunct to clinical signs and symptoms to inform management decisions. This is important to help reduce inappropriate radiation exposure, fear and anxiety in children as well as supporting hospital savings. Further research with larger prospective studies would be beneficial to confirm the findings of the current literature and facilitate a change in routine clinical practice.
Clinical bottom line
Following chest drain removal, close clinical observation of respiratory function, signs and symptoms is favourable over routine chest radiography (grade B).
Routine radiography following chest drain removal may be reserved for symptomatic patients only (grade B).
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
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