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Editorials |

Death to the Garden Hose?

Michael H. Baumann, MD, FCCP
Author and Funding Information

From the University of Mississippi Health Care.

Correspondence to: Michael H. Baumann, MD, FCCP, University of Mississippi Health Care, 2500 North State St, Jackson, MS 39216; e-mail: mbaumann@medicine.umsmed.edu


Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestpubs.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;137(3):512-514. doi:10.1378/chest.09-2221
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Extract

“Bigger is better” is commonly perceived as the appropriate approach to many problems within and outside of the medical world. This approach has generally applied to drainage of pleural infections. The British Thoracic Society (BTS) Guidelines for the Management of Pleural Disease note no consensus regarding the optimal chest tube size in pleural infection while commenting on the traditional use of bigger bore chest tubes for drainage of pleural pus.1 Similarly, a recent pleural textbook notes that larger chest tubes (28F to 36F) have been recommended in the past for pleural infection based on the belief that smaller tubes would become obstructed.2 Both publications remark upon the clinical success of smaller tubes, but do not definitively define parameters for their use. In this issue of CHEST (see page 536), Rahman and colleagues2 help dispel the perception of bigger being better in pleural infection. To my knowledge, this is the first study that compares small vs large tube-related outcomes in a prospectively studied population of patients with pleural infection. Using a post hoc analysis of First Multicenter Intrapleural Streptokinase Trial (MIST1) prospective data, the authors find no significant difference in the frequency of death or of required thoracic surgery in patients receiving smaller chest tubes (≤ 14F) vs larger tubes. Secondary outcomes, including length of hospital stay, improvement in chest radiograph, dynamic lung function (FEV1 and FVC), and adverse events, are also no different. Overall pain scores are higher in patients managed with larger size chest tubes than smaller tubes and in patients treated with blunt dissection-inserted tubes compared with guide wire-inserted tubes. Strikingly, the occurrence of moderate-to-severe pain is reduced by half when using smaller tubes.

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