I've seen the following sequence of events several times. I can't prove the exact causality, but I have a strong suspicion about what is going on here. You can be the judge.
clinical presentation
- A patient presents for management of a pleural effusion.
- A pigtail chest drain is inserted without difficulty or complication.
- The drain ends up in a shallow position, extending only a few cm into the pleura. This may result from initially inserting the drain in a shallow position, or if the drain gets pulled partially out of the chest.
- Subsequently, the patient develops a pneumothorax with dramatic subcutaneous emphysema (much worse than would typically be expected from a pneumothorax). “Michelin” refers to the development of markedly severe subcutaneous emphysema.
what I think is happening
- When the pigtail tube is almost entirely pulled out of the chest, the rounded “pigtail” end is forced to straighten out. This leaves the pointy end of the tube protruding directly into the delicate lung tissue. Over time, this pointed end of the tube pierces the lung, causing a pneumothorax.
- The tip of the pigtail chest tube is in the pleura, but some side-holes of the chest tube are within the chest wall. In this position, the tube may conduct gas from the pleural space directly into the subcutaneous space. By creating a direct conduit between the pleura and the subcutaneous tissue, the pigtail facilitates the development of a dramatic amount of subcutaneous emphysema.
how to avoid Michelin Chest Syndrome
- Err on the side of placing pigtail chest tubes deeply. Even if the pigtail tube curls around within the pleura, it generally works fine (i.e., it doesn't kink off or obstruct).
- Secure pigtail chest tubes well, to avoid having them partially withdrawn.
how to treat Michelin Chest Syndrome
- The pigtail chest tube must be removed. Even if it seems to be working, the pigtail is in a shallow location that could be easily displaced. Furthermore, it's possible that the chest tube could be intermittently straightening out and causing more lung injury.
- A new chest tube needs to be inserted to manage the pneumothorax. In the context of dramatic subcutaneous emphysema, it may be difficult to safely insert a pigtail catheter – so a surgical chest tube may be required.
related prior literature
- Jones et al. described a series of 167 patients treated with chest tube placement. 25 of these patients developed subcutaneous emphysema, of whom 5/25 were noted to have side-hole misplacement within the chest wall (example below). In comparison, zero of the 109 patients without subcutaneous emphysema had a malpositioned side-hole within the chest wall. This statistically significant correlation between subcutaneous emphyxema and malpositioned a side-hole (p<0.01) may support a causal relationship. (11422886)
(Opening image credits: Photo by Ye Massa on Unsplash)
Josh is the creator of PulmCrit.org. He is an associate professor of Pulmonary and Critical Care Medicine at the University of Vermont.
Latest posts by Josh Farkas (see all)
- PulmCrit Wee – Loading infusion auto-titration (LIAT) for infused medications with intermediate half-lives - March 23, 2025
- PulmCrit Wee: Michelin Chest Syndrome - March 15, 2025
- PulmCrit: ADAPT and SCREEN trials are full of sound and fury, signifying little - December 13, 2024
Thank you very much for each of your posts.
Greetings from Chile!
Nice post, I’ve seen this occasionally. I always wondered why the ‘standard’ pigtail (everywhere I’ve worked uses a Wayne) is non-locking. A locking pigtail seems safer with no major downside, and would mostly prevent this.
For extensive subcutaneous emphysema – I’ve seen some practices, Advice/ advocate making a Superficial subcutaneous incisions to Relieve the emphysema . Is that safe?
The Peripheral Vascular Essentials course at Apollo Simulation Centre is a one-day comprehensive training program designed for healthcare professionals to enhance their skills in managing peripheral vascular interventions. This course covers essential techniques, including angioplasty, stenting, and embolization, and provides hands-on training with state-of-the-art equipment. The course is structured with online modules that offer foundational knowledge on Cath lab materials, radiation protection, and interventional radiology (IR). Participants will also gain expertise in access techniques and vascular interventions during the contact course, with 70% of the time devoted to practical exercises and demonstrations by experts. The course is coordinated by Dr.… Read more »