Pigtails should replace chest tubes for most pneumothoraces and pleural effusions requiring drainage. In this episode, I discuss points on use and placement. The next post will be a video on an actual placement. Please put your comments and thoughts below.
For a video of the procedure,
come on over here:
Updates:
- See a real-time ultrasound placement from ThinkingCC
- ThinkingCC's thoughts on Pigtails
- GRAVITAS RCT
- Safe even in coagulopathy and anti-plt
Additional New Information
More on EMCrit
- EMCrit 312 – Tube Thoracostomy (Chest Tubes) Part 1 Peri-procedural Chest Tube Stuff(Opens in a new browser tab)
- EMCrit 313 – Tube Thoracostomy (Chest Tubes) Part 2(Opens in a new browser tab)
- Podcast 62 – Needle vs. Knife II: Needle Thoracostomy?(Opens in a new browser tab)
Additional Resources
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What kind of kit is that? Is it specific for chest drainage?
Ours is the Wayne pneumothorax kit, but all of the companies make a seldinger 14 french pigtail kit
Nice work.. A two people team just for explanation i think? (usually in our setting there’s only one operator for this simple procedures). I was shocked by the stichtes done hands only! This is a nice way to get some risk…. 😉 anyway i agree with the larger implementation of pigtails in thoracic draineage. They can easily and less invasively solve most of the pnx and pl. Effusions (forgive my bad English…)
2 person team b/c the junior had never done a pigtail. Imagine you are not at a teaching shop then, Luca? Definitely commented during the video that one should not drive the needle by hand (said as I was doing it of course : )
Hey Scott, great stuff as always. A couple categories of patients in which I’d urge caution (though not hard contraindications) with pleural pigtails are 1) those with bullous lung disease (ie, emphysema). I’ve seen a couple of these go into peripheral blebs leading to irreparable bronchopleural fistula, and 2) those with cirrhosis and pleural effusion. If it’s hepatic hydrothorax, it may drain forever, leading to substantial fluid and protein loss.
agree with both of those–but for me those are worries for any thoracic drainage techniques. Having seen the results of a Kelly through a bleb–it ain’t a pretty post-procedure course
Please always use a needle holder in the future. Basic rule: You never touch the needle of the skin suture with your hands. That’s what I teach all my assistant doctors. Otherwise it’s only a matter of time until the tip of the needle is in your fingers! I speak from experience.
Thanks for the great video.
Great post as always Scott! I’d also recorded a brief narrative and video for the residents who inevitably come out of a rotation with us pigtail-certified!
https://thinkingcriticalcare.com/2018/09/26/a-primer-on-pigtail-insertion-foamed-foamcc/
video:
It’s really an invaluable technique for cc/er/hospitalists
At my last shop the trauma folks started doing more pigtails for pneumothoraces and seemed to have a run of failures (inadequate drainage). Don’t know why, perhaps blood. I think there are some definite technical aspects to making these effective, versus just getting them into the pleural space.
there really isn’t–i wonder if they were trying to use 8.5 F pigtails which I think are too small for this purpose.
Why would an 8.5fr tube be to small to evacuate air from the pleura? (I hate the cook 8.5fr kit- the wire is flimsy and it’s just awkward). But my poiny is you can smaller yes even 6fr thoracentesis kit with ease for pneumothorax. The key is keeping those holes patent- which can be done if you flush the tube twice a day with normal saline. Any tube smaller than 14fr is at risk of clogging and really should be flushed.
yes, of course any size will drain a simple pneumo. Problem with traumatic pneumothoraces is that they are rarely only isolated air–they almost always have blood as well. I think your flushing idea would probably solve many of the problems with the smaller tubes–but I would be reluctant to think that is a good plan until somebody does the study on lack of increase in epyema from that practice.
Cook Medical says the Wayne Pneumothroax kit can be placed using a trocar technique too. What are your thoughts for using this in prehospital care if systems cant do chest tubes or finger thoracotomies?
trocars are the worst idea in medicine–would avoid these at all costs
Thanks for a nice tutorial as always. Som great tips in there for beginners and experienced clinicians alike. I don´t know if you use the thinner Zeldinger kits as well but from comments below I gather not. We use 8-20 Fr kits for Zeldinger placement which is great so that you can adapt to their patient needs. Simple pneumo’s is fine with a 8Fr pigtail and often for clear pleural fluid as well and are so nimble and atraumatic for the patient.. Then work your way up the sizes depending on the contents. The 20Fr works great for all but… Read more »
I use Seldinger 8.5 F if I am sending a patient home, 14F for pleural effusion/inpt pneumo, and we have a 20F Seldinger formal chest tube for hemothorax/empyema.
Scott, I love that you’re advocating the use of ultrasound and recognition of the need for adequate analgesia. Ever use a serratus/PECs/erector spinae block with something like ropivacaine to provide some long lasting analgesia for chest tubes/pigtails? Seems like you’re already there with the ultrasound and could buy your patient some narcotic free analgesia. I’ve done blocks with chest tubes with decent results, but not pigtails (yet). I know folks are actively researching this but I’m curious about your thoughts. Do pigtails need the same amount of analgesia or is insertion the worst part?
my patients rarely complain about the pigtails like they do with chest tubes.
Great video and extremely helpful for those of us learning new techniques for chest tube insertion. Thanks for all you guys do for teaching the rest of us in community/rural hospitals without the resources of large medical centers!
Hi, thanks for this.
What size and length needle do you use for anesthesia?
22G 1.5 inch
Does the internal pigtail lock onto the internal dilator? I have had some difficulty aligning both holes so the wire easily fits.
Which companies do people recommend for purchasing a pigtail chest catheter
Hey Scott, Great video as usual. We’re trying to get these for our shop. Does the Wayne PTX kit come with the adapter to the heimilich valve, that was shown in the video?
yes
Scott,
Tried to do a modified percutaneous pigtail for pleural effusion today on a big patient with lots of adipose. Couldn’t use seldinger because the needle wasn’t long enough for the adipose so I tried to pass the pigtail w/trochar along my finger but ran into trouble. It’s just too flexible and has a bit of an innate curve so it wants to track away into subQ. Had to resort to 20F chest tube and kellys. Any tricks for getting that pigtail to the rib space?
My favorite thing to do is grab a cook airway exchange catheter and sterilely cut it down to 25 cm on my field. That slides along your finger beautifully, then put the wire through it and take it out and continue the procedure without the dilator step
HI Scott. Nice video. Clean concise communication to ‘student’ and other staff. I too find these close to painless for patients, as well. Question, What is your process, re requesting of patients consent to film and publish. General interest cw Australia. Ta
Our hospital has a specific consent form for this purpose which specifies all possible uses and streamlines the process
Thank you for the video! Big question: Wondering if the stopcock can be removed for spontaneous pneumothorax?? Or What would be the benefit of the stopcock? I could see a reason for pleural effusion. Sorry asking for a friend. We had an issues where the stopcock somehow turned (assuming when patient was adjusting himself) and was hidden under a bandage that lead to re-occurrence of the pneumothorax in the patient.
not sure the distinction between thoracentesis and pigtail? isn’t that just another way to do thoracentesis? you send patients home with an 8 French but not 14? also do you ever use the thoracic vent for spontaneous ptx?
thoracentesis is a drainage of fluid from the chest without leaving a long-term catheter in place. you can use a pigtail to do a thoracentesis. if you send a pt home, you need a thoracic vent
The incision was not big enough in the video, that’s why the skin was invaginating markedly when the dilator was first being advanced
going to have to respectfully disagree.
i put 25F ECMO cannulae in with that size incision.
That is what the skin is supposed to do.
With proper dilation, a skin incision is not even necessary.
Hey Scott, I have two questions for you: 1) I’ve had 2 patients experience tremendous and persistent pain after pigtail insertion. Why does this happen, how can I prevent it? I’ve heard colleagues have witnessed similar things. 2) I’ve had an attending insist to me that during pre-pleural advancement of the pigtail I should angle the pigtail in my desired direction (i.e. superiorly for ptx). However, it seems to me that I should use a perpendicular approach until I penetrate in order to avoid hiting an artery. He counered that the artery was less of a concern with pigtails, so… Read more »
in general, pigtails will go wherever they please–i wouldn’t stress to much about it–the entire pleural space will drain unless there are loculations
in terms of pain, we need to separate out pigtails for large pneuomothoraces in which there is generally far more pain from lung expansion rather than the pigtail