Authors: Richard C. Briones, Marla Vina A. Briones, Kathleen S. Cruz, Realyb B. Dongaban
Categories: Original Article, chest tube, tube thoracostomy, morbidity, complications
Source: Acta Medica Philippina
Closed Tube Thoracostomy Morbidity Rate in a Philippine Tertiary Government Hospital: 6-Year Review
Authors: Richard C. Briones, Marla Vina A. Briones, Kathleen S. Cruz, Realyb B. Dongaban
Abstract
Background and Objective
Closed tube thoracostomy is one of the most common hospital procedures known for its effectivity and safety; however, complications may occur, leading to poor patient outcomes. To date, the burden of morbidity among patients who underwent closed tube thoracostomy in the Philippines remains unknown. Therefore, this study aims to determine the in-hospital morbidity rate among patients who underwent closed tube thoracostomy in a tertiary government hospital.
Methods
This is a descriptive cross-sectional study of admitted patients who underwent closed tube thoracostomy at Bicol Medical Center from 2015 to 2020. Data were collected by reviewing medical charts.
Results
A total of 376 patients were included in the study. Morbidity rate was 15.16% (95% CI: 11.69-19.19%), and majority were due to improper chest tube placement. Compared to those without complications, a higher proportion of patients with complications had pleural effusion and had chest tube failure (both p≤0.05). The median operative time was also significantly longer in patients with complications compared to those without complications (p=0.0012). Mortality was significantly lower in patients with complications than those without complications. Total and postoperative length of stay were significantly longer in patients with complications than those without complications (p<0.00001).
Conclusion
Complications after closed tube thoracostomy are common. Across all variables analyzed, only indication of chest tube insertion, operative time, and occurrence of chest tube failure were found to differ between patients with and without complications. Moreover, patients with complications had longer length of stay than those without. Reducing positional tube complications may help decrease in-hospital morbidity.
INTRODUCTION
Closed tube thoracostomy (CTT) is one of the most common procedures performed in hospitals, especially among trauma patients.^1,2^ However, despite its effectivity and safety, several studies now emphasize the high complication rate associated with chest tube insertion and removal.^3–5^ Based on previously published international studies, 16-20% of CTT patients experience morbidity.^5–7^ This often leads to additional patient burden.^7^ CTT complications tend to increase patient hospitalization costs due to operative and/or radiologic intervention.^7–9^ The limited evidence-based guidelines on chest tube management can potentially affect patient clinical outcomes.
Using the standardized format suggested by Aho et al., CTT complications can be classified into insertional, positional, removal, infectious/immunologic, and instructional/educational/equipment.^10^ Using this classification, the authors established a standard definition, allowing comparability between studies. Positional complications are more common, especially among low-resource hospitals that are not using imaging techniques.^7^ Therefore, the difficulty in managing this complication requires early recognition and intervention.^5^
CTT is still widely performed in low-resource hospitals such as Bicol Medical Center (BMC). The burden of CTT complications in the local setting remains unknown. In addition, only a few studies have been published using the standard format of classifying CTT complications.^10^ This study, therefore, aims to determine the in-hospital morbidity rate of CTT in a tertiary government hospital in the Philippines. The study also aims to compare the characteristics and outcomes of patients who developed and did not develop CTT-related complications.
MATERIALS AND METHODS
The researchers utilized a descriptive cross-sectional study design. All admitted patients, regardless of age, who underwent CTT at BMC from January 2015 to December 2020 were included in this study. Both service and private patients that were admitted for at least 24 hours with any indication for initial chest tube insertion were included. Patients who had previous CTT, required bilateral CTT, underwent other thoracic procedures other than CTT during the same admission, and who had unsuccessful insertion were excluded.
At BMC, CTT is performed in the operating theatre by general surgical residents. Unstable patients, however, undergo chest tube insertion in the emergency room. Chest X-ray is obtained in most patients before CTT to confirm the diagnosis of thoracic pathology. When indicated, patients undergo CTT via a blunt dissection technique under local anesthesia.
The minimum sample size requirement was computed using OpenEpi. Setting the prevalence of CTT complication at 19%, a maximum tolerable error at 5%, and a 95% confidence level, a minimum of 236 CTT patients are required.^5^ However, to capture the data of all CTT patients, the researcher utilized a total enumeration technique wherein all eligible patients were included in the study.
The study was approved by the Bicol Regional Training and Teaching Hospital-Institutional Review Board (BRTTHIRB Protocol No. 2021-020). Since no direct patient contact was involved, informed consent was waived for this study. The following data were collected via a retrospective review of medical charts from September to December 2021. Age, sex, patient classification, comorbidities, injury type, time to CTT (i.e., number of hours from injury or referral to CTT), hemodynamic instability (i.e., at least one abnormality on vital blood pressure, heart rate, respiratory rate, and oxygen saturation), the urgency of CTT, CTT setting, imaging technique during insertion, endotracheal intubation, chest tube indication, surgeon expertise, advanced training program, chest tube size, rib insertion interspace, use of suction, use of antibiotic prophylaxis, operative time, anesthesia type, chest tube duration, mechanical ventilation, re-intervention after chest tube failure (i.e., unexpanded lung), result of chest tube failure, respiratory therapy, mortality, total length of stay, and postoperative length of stay were recorded. Appendix A presents the operational definition of variables collected.
The type of in-hospital morbidity experienced by patients was assessed by two independent reviewers, and any discrepancy was resolved through discussion. Complications were classified based on Aho et al.'s standardized format for reporting complications.^10^ Only complications arising from the index CTT were analyzed. Complications resulting from re-CTT procedures were not included in the analysis.
Stata MP version 17 was used for data processing and analysis. Continuous variables were presented as median/interquartile range (IQR) due to the non-normal distribution based on Shapiro-Wilk's test. Categorical variables were expressed as frequency and percentages. Mann-Whitney U test was used to compare continuous data. The Chi-square and Fisher's exact tests were used to analyze categorical data. P-values ≤0.05 were considered statistically significant.
RESULTS
A total of 425 patients underwent CTT at BMC from 2015 to 2020, of which 376 patients were eligible and were included in the analysis (Appendix C).. Fifty-seven (57) developed in-hospital morbidity. CTT morbidity prevalence was 15.16% (95% CI: 11.69-19.19%). Specific CTT complications are summarized in Table 1. Only five patients developed two simultaneous complications. The most common complication was positional (57.89%, Figure 1), wherein the chest tube was found to be kinked or obstructed (Table 1).
Table 2 presents the demographic and clinical profile of CTT patients. Comparative analysis by presence of complications was performed. The median age was 47 (range: 1 to 86 years old), and most were between 18 and 60 years old. The majority were males and were admitted as service patients. The most common comorbidity was pulmonary tuberculosis, which affected 41% of patients. Injury types at the thoracic cavity were predominantly non-trauma related. Hemodynamic instability was recorded in only 13% of patients. Only 5% had endotracheal intubation at the time of CTT. More than half of the patients underwent CTT due to pneumothorax (51%), while 40% were due to pleural effusion.
There was no significant difference observed between patients with and without complications in terms of age, sex, patient classification, comorbidities, injury type, and prior endotracheal intubation. The indication for CTT placement was the only one found to be significantly different. Specifically, patients with complications had more incidence of pleural effusion than those without complications (67% vs. 35%, p<0.0001) Pneumothorax was less in patients with complications than those without complications (30% vs. 55%, p<0.0001).
The intervention performed on patients with and without complications are compared in Table 3. The median time from injury/referral to CTT was 1.1 hours. More than half (55%) of the patients underwent CTT in the ER setting, and only 3% underwent image-guided insertion using ultrasound. None of the patients underwent computed tomography (CT)-guided CTT. More than half (55%) of CTTs were performed by junior residents, and only 9% were performed by consultants. Fifty-nine percent (59%) of patients were inserted with a 32 Fr chest tube and 45% were placed in the 5^th^ mid-axillary line (MAL) while 37% were at the 6^th^ MAL. Only a few (2%) patients underwent suction during drainage. One percent underwent antibiotic prophylaxis before chest tube insertion. Most patients underwent local anesthesia without sedation (79%).
None of the patients received respiratory therapy after CTT. Only 240 patients had their chest tubes removed before discharge. These patients' median chest tube duration was 9.1 days (range: 0.7-45.9 days). Chest tube failure, primarily due to unexpanded lungs, was recorded in 18% of patients. Among the 69 patients with chest tube failure, 36% were shifted to a modified Heimlich valve, 32% underwent another CTT, 17% had thoracoscopy, 7% had thoracotomy, and 7% received no additional procedure.
Only operative time and chest tube failure were found to be significantly different by the presence of CTT complications. The median operative time of patients who developed complications was significantly higher than those who did not develop complications (p=0.0012). Furthermore, a higher proportion of patients who developed complications had chest tube failure than those who did not develop complications (70% vs. 9%, p<0.0001).
Table 4 presents the clinical outcomes of CTT patients. Sixty-nine CTT patients died during hospital stay, with an incidence of 18% (95% CI: 14.57-22.64%). Among the patients who died, the median time from admission to death was 12 days [IQR: 5-22], while the median time from CTT to death was seven days [IQR: 1-14; Range: 0-37 days]. Among survivors, the median total length of hospital stay was 16 days (range: 4-53 days), and the median post-operative length of stay was 14 days (range: 0-47 days).
A significantly lower proportion of patients with complications died than those without complications (p=0.016). In addition, patients with complications had significantly longer total length of stay (p<0.00001) and postoperative stay (p<0.00001).
DISCUSSION
In recent years, studies on CTT morbidity have been gaining popularity worldwide. However, to the best of the researcher's knowledge, this is the first study done in the Philippines that explores the burden of morbidity among patients who underwent CTT. Although the present study only included patients from one institution, the results may serve as baseline information for future local studies.
Overall CTT morbidity in this study was 15.16%. This is close to the estimates of previous studies which utilized Aho et al. definition and classification of CTT morbidity ranging from 16-20%.^5–7,9,10^ Among those who developed CTT morbidity, 57.89% were classified as positional, wherein chest tubes were found to be kinked or obstructed. This finding was similar to a study done in South Africa where most complications were also classified as positional.^7^ A study done in Finland and the US also reported that most (69-97%) complications were positional.^8,9^
The study by Sritharen et al. showed that insertional complications (38%) are the second leading cause of CTT morbidity.^7^ In contrast, the present study recorded no insertional complication among CTT patients. The composition of the patient population may explain the difference in rates. In the study by Sritharen et al., chest tube insertion was challenging probably due to a high proportion of blunt trauma patients.^7^ In contrast, the population in this study is primarily non-trauma patients.
Although imaging techniques are widely available to minimize positional and insertional complications, in lowresource settings like BMC, radiographic imaging is not routinely performed.^5,11^ Only 3% of patients in this study underwent ultrasound-guided CTT, and none utilized a CT scan. Positional-related morbidities require complex intervention and may result in worse patient outcomes if not addressed promptly. Therefore, early recognition of this complication is important. The lack of guidelines on imageguided CTT should also be reviewed to prevent these types of complications.
In this study, the second leading complication was infective, specifically empyema. This affected 13 of the 376 CTT patients (3.46%) which was within the range reported by previous studies.^4,7,12–15^ Prophylactic antibiotic administration lowers the risk of empyema; however, only 1% of patients in the study received this intervention. In a study by de Abreu et al., infections may also be reduced by performing the CTT in the OR.^16^ In this study, however, 55% of the procedures were performed in the emergency room.
This study observed that the indication for CTT was significantly different between patients with and without complications. A higher proportion of patients with complications underwent CTT due to pleural effusion compared to those without complications, similar to the findings of a published study.^9^ Pleural effusion is one of the leading causes of morbidity; similar to the result of this study. Unfortunately, published studies did not explore this finding; hence, no comparison can be made. Patients with prolonged operative time may have complex thoracic pathology, thus, increasing the likelihood of postoperative complications.
Chest tube failure, defined as having unexpanded lung in this study, was also higher in patients who developed complications than those who did not develop complications. Given that most complications were positional, chest tubes were likely to be non-functional; hence, the possible reason why chest tube failure was higher in these patients. A similar result was observed in a study in Brazil wherein a higher proportion of patients with complications required chest tube re-insertion due to non-functioning drains.^14^
Overall in-hospital mortality was 18% close to that estimated by a study done in Brazil.^14^ Mortality was much lower in patients who developed complications than those who did not. This finding can be explained by the fact that mortality was defined as death due to any cause during their hospital stay, not just because of CTT. The current study design inhibits further assessment of CTT-related death since the researchers only rely on what was written in medical charts. Similar to previous studies, patients with complications had significantly increased length of hospital stay.^9,15^
This study has several limitations. First, only one institution was included. The results may, therefore, have limited generalizability since the characteristics of the patients may be different compared to those admitted in other institutions, specifically, private hospitals. Second, BMC is a training institution, hence, general surgery residents-intraining were primarily performing the CTT. The skill level of the trainee was not available and has not been accounted for during the review of the records. However, patient outcome could have been affected by the difference in skill level and experience. Third, only specific complications are provided in the medical charts. In order to minimize misclassification bias, two independent researchers determined the presence/absence of complications as well as the category of classification. Fourth, the study mainly aims to assess the burden of CTT morbidity in the chosen study setting to serve as baseline data for future local studies. The descriptive design of this research was limited to the comparison of patient characteristics and outcomes; and examination of relationship of morbidity with other variables was not yet considered. Last, the data were collected via a retrospective review of medical charts. This limits the researcher from collecting more information about patient’s cause of death (i.e., whether related to CTT or not). In addition, the researchers can only assume the completeness and accuracy of the data from patient charts. Quality control was performed during data processing by performing consistency checks. The primary investigator verified inconsistent encoded data from the medical charts.
The large sample size and inclusion of all CTT patients for six years is one of the study's strengths. After an extensive literature search, all possible variables in the medical charts that may influence morbidity rates have been explored. The present research highlights that CTT morbidity is common in BMC, the chosen study setting. Therefore, interventions and strategies that are known to minimize positional complications should be implemented to ensure better patient outcomes. The feasibility and cost-effectiveness of image-guided CTT in BMC should be explored. The CTT complications and outcomes of trauma versus non-trauma patients should be further examined by future researchers. The association of CTT morbidity with patient outcomes such as mortality and prolonged length of stay warrants further analysis. Moreover, predictors of mortality among CTT patients should also be explored.
CONCLUSION
Complications after closed tube thoracostomy are common. Across all variables analyzed, only indication of chest tube insertion, operative time, and occurrence of chest tube failure were found to differ between patients with and without complications. Moreover, patients with complications had longer length of stay than those without. Reducing positional tube complications may help decrease in-hospital morbidity.