How To Do It: Thoracic Pigtails
A 31 year old male with a history of leiomyoscarcoma and metastasis to the lungs presents to the emergency department for 2 days of shortness of breath. He had been on chemo up until last month when he decided to stop all medical interventions. He denies fevers, chills, chest pain, nausea, vomiting, diarrhea, constipation, and changes in stool habits.
Physical Exam and Pertinent Labs
T 98.6, HR 86, BP 118/73, RR 26, SaO2 94%
General - Awake, alert, oriented x4
CV - Regular rate and rhythm, No jugular venous distension
Pulm - Decreased breath sounds on the right with dullness to percussion
CBC and Chem-8 WNL
Bedside US demonstrates a right sided pleural effusion
CXR/CT Chest demonstrated right sided pleural effusion.
A 14 french pigtail catheter was placed with successful drainage of the pleural effusion and improvement of respiratory rate/O2sat.
Take Away #1:
Optimal candidates for pigtail catheters are those with thin, free flowing fluids such as air or new pleural effusions
Take Away #2:
Contraindications: Unstable patients, empyema, traumatic (hemothorax), loculated pleural effusion (unlikely to successfully drain).
Caution when using pigtails on those with emphysema out of concern for entering a peripheral bleb creating a broncho-pleural fistula.
Take Away #3:
There is limited data, but the literature demonstrates no significant differences in mechanical ventilations use, number of tube days, or the number of ICU days when comparing chest tubes to pigtails
Take Away #4:
Triangle of safety lives between the latissimus dorsi, pectoralis major, and the 5th intercostal. Insert here to avoid accidentally entering the ventricles or liver.
Daniel Brodmerkel, DO is a current first year resident at Stony Brook Emergency Medicine.
Edited by Bassam Zahid, MD