Is a Chest Radiograph Required After Removal of Chest Tubes in Children?

Ellen McGrath, PNP; Lee Ranstrom, PNP; Debra Lajoie, PhD, RN; Lauren McGlynn, PNP; David Mooney, MD, MPH

Disclosures

J Pediatr Health Care. 2017;31(5):588-593. 

In This Article

Results

We identified 468 potential patients who underwent a thoracic procedure that met the search criteria. Of these, 184 patients had no chest tube left in place, and three were excluded (one had a cardiac procedure, one was transferred to another hospital with a chest tube in place, and one did not have postremoval chest radiography). The remaining 281 patients who had a chest tube and a postremoval chest film made up the study group.

In 263 patients (93.6%), there was no change in the postremoval chest radiograph compared with the preremoval radiograph. Eighteen patients (6.4%) had any change in chest radiograph result. Of these, six patients (2.1%) had an increased pneumothorax, six (2.1%) had a new or worsened opacity or density of the lung, three (1%) had a new or increased pleural effusion, and three (1%) had a new pneumothorax (two small, one tiny; Table 2, Table 3 and Figure).

There were two subgroups within this population, esophageal atresia (EA) and other general surgical cases. The EA group differed significantly in length of chest tube placement, age, and duration of hospital stay compared with the remainder of the general surgical population. EA patients were differentiated because these patients typically have esophageal and not pulmonary operations, and we expect a different rate of postremoval complications. The EA cohort of patients is followed by the general surgery team, but they differ from most of the general surgical patients because they often have a staged repair of the esophagus (long gap esophageal atresia), with paralysis for 10 to 14 days, during which time the chest tube remains in place. The Figure outlines those differences. The remainder of the general surgical population had similar sample demographics.

Of the 18 patients who had a change in their postremoval chest radiographs, six had no change in their clinical management. Eight patients were administered oxygen despite not experiencing any desaturation episodes or respiratory symptoms (six for pneumothoraces and two for pleural effusions). Two patients had a repeat chest radiograph taken the following day to reassess the lung fields. No patient returned to the operating room.

Two patients (0.7%) required an intervention, both secondary to clinically significant changes after chest tube removal and both after benign postremoval radiographs. The first occurred in a 1-week-old male newborn on Postoperative Day 5 after congenital cystic adenomatoid malformation resection. The initial postremoval radiograph showed a small pneumothorax that was not addressed given the infant's lack of symptoms. Twelve hours later, the infant developed respiratory distress, and a second chest radiograph showed a large pneumothorax, prompting replacement of the chest tube. The second occurred in a 4-year-old boy with a history of lung transplantation on Postoperative Day 3 after a lung biopsy. The postremoval radiograph was unchanged, but the patient developed worsening problems with oxygenation and required reintubation, which appeared to be unrelated to the chest tube removal.

The incidence of postremoval complications was so low that we are unable to determine a risk stratification using these data.

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