Pigtail catheter for pleural drainage: Tips to minimize complications

Traditionally large-bore tube thoracostomy has been the standard of care for treating many acute intrathoracic pathologies [1]. However, the advent of less invasive small-bore chest tubes, also known as pigtail catheters, has gradually led to a paradigm shift. Pigtails provide a less invasive and often better tolerated alternative to traditional chest tubes and allow for adequate treatment of pneumothoraces and uncomplicated pleural effusions [1-5]. Unfortunately, these less invasive catheters are not without complications – both unique and similar to traditional chest tubes.

Case

A 48 year-old male with a history of hypertension and polysubstance abuse presented to the emergency department (ED) for shortness of breath and was found to have a left sided parapneumonic pleural effusion (Figure 1). The patient underwent thoracentesis and placement of a pigtail catheter using the Seldinger technique to drain the fluid collection. Pigtail catheter placement was confirmed by chest x-ray (Figure 2).

Figure 1: Chest x-ray with left sided pleural effusion

Figure 2: Chest x-ray with the pigtail catheter in the left chest

Case Progression

Despite pigtail catheter placement, there was minimal drainage from the catheter. In collaboration with the inpatient team, intrapleural thrombolytics were administered via the pigtail catheter did not resolve the issue. Although the patient’s chest x-ray did improve after the procedure, the patient continued to deteriorate clinically and became increasingly hypoxic.

A CT angiogram was then performed and showed that the pigtail catheter had been accidentally introduced through the lung parenchyma and was lodged in the left main stem bronchus (Figure 3). This was confirmed on bronchoscopy (Figure 4).

Figure 3: Chest CT angiogram showing the pigtail catheter (arrow) in the left mainstem bronchus

Figure 4: Bronchoscopy view of the left mainstem bronchus showing the pigtail catheter

This case highlights one of the more rare and potentially severe complications of small-bore chest tubes. With the increasing utilization of such devices, this case  highlights the need for better education about the indications, complications, and troubleshooting approaches with these pigtail catheters. 

Complications

The overall complication rate for small-bore catheters is lower than their large-bore counterparts, partly because of their smaller caliber. Also unlike traditional large-bore tube thoracostomy, the lack of tactile feedback (not feeling the pleural puncture ‘pop’ with Kelly clamps and then identifying the intrapleural space with the finger) can lead to malpositioning complications. Both approaches, however, share common complications:

• Most common complication: Chest tube kinking and obstruction [6, 7, 10]
  • Due to the small caliber of the pigtail catheter, it can easily become twisted or kinked between the pleura and lung parenchyma, obstructed within lung fissures, or kinked externally between the body and environment [9].
  • Obstruction may also occur from clotted blood [9] or pleural effusion loculations [12, 13] within the catheter lumen.
    • For loculated effusions and empyemas, an interdisciplinary inpatient discussion should weigh the pros and cons of intrapleural thrombolytics versus surgical drainage and pleurodesis.
    • One often used thrombolytic regimen is the MIST-II protocol, which involves the combination of alteplase (tPA) 10 mg BID plus dornase alfa (DNase) 5 mg BID [13, 14].
• Laceration of tissue/vessel [2, 3, 6, 8]
  • Can be prevented by using standard landmarks and inserting above the rib margin
• Air emboli [2, 3, 6, 9]
  • Thought to be due to parenchymal injury resulting in a fistula involving the pulmonary vessels
• Parenchymal injury [9]

References

1. Gammie JS, Banks MC, Fuhrman CR, et al. The pigtail catheter for pleural drainage: a less invasive alternative to tube thoracostomy. JSLS: Journal of the Society of Laparoendoscopic Surgeons. 1999;3(1):57-61. PMID: 10323171
2. Saqib A, Ibrahim U, Maroun R. An unusual complication of pigtail catheter insertion. Journal of Thoracic Disease. 2018;10(10):5964-5967. doi:https://doi.org/10.21037/jtd.2018.05.65
3. Broder JS, Al-Jarani B, Lanan B, Brooks K. Pigtail Catheter Insertion Error: Root Cause Analysis and Recommendations for Patient Safety. The Journal of Emergency Medicine. 2020;53(3). doi:https://doi.org/10.1016/j.jemermed.2019.10.003
4. Vetrugno L, Guadagnin GM, Barbariol F, et al. Assessment of Pleural Effusion and Small Pleural Drain Insertion by Resident Doctors in an Intensive Care Unit: An Observational Study. Clinical Medicine Insights Circulatory, Respiratory and Pulmonary Medicine. 2019;13:1179548419871527. doi:https://doi.org/10.1177/1179548419871527
5. Kulvatunyou N, Vijayasekaran A, Hansen A, et al. Two-year experience of using pigtail catheters to treat traumatic pneumothorax: a changing trend. J Trauma. 2011;71(5):1104-1107. doi:https://doi.org/10.1097/ta.0b013e31822dd130
6. Remérand F, Luce V, Badachi Y, Lu Q, Bouhemad B, Rouby JJ. Incidence of Chest Tube Malposition in the Critically Ill. Anesthesiology. 2007;106(6):1112-1119. doi:https://doi.org/10.1097/01.anes.0000267594.80368.01
7. Horsley A, Jones L, White J, Henry M. Efficacy and Complications of Small-Bore, Wire-Guided Chest Drains. Chest. 2006;130(6):1857-1863. doi:https://doi.org/10.1378/chest.130.6.1857
8. Hyo Jin Kim, Yang Hyun Cho, Gee Young Suh, Jeong Hoon Yang, Jeon K. Subclavian Artery Laceration Caused by Pigtail Catheter Removal in a Patient with Pneumothorax. The Korean Journal of Critical Care Medicine. 2015;30(2):119-122. doi:https://doi.org/10.4266/kjccm.2015.30.2.119
9. Anderson D, Chen SA, Godoy LA, Brown LM, Cooke DT. Comprehensive Review of Chest Tube Management: A Review. JAMA surgery. 2022;157(3):269-274. doi:https://doi.org/10.1001/jamasurg.2021.7050
10. Aho JM, Ruparel RK, Rowse PG, Brahmbhatt RD, Jenkins D, Rivera M. Tube Thoracostomy: A Structured Review of Case Reports and a Standardized Format for Reporting Complications. World Journal of Surgery. 2015;39(11):2691-2706. doi:https://doi.org/10.1007/s00268-015-3158-6
11. Gayer G, Rozenman J, Hoffmann C, et al. CT diagnosis of malpositioned chest tubes. Br J Radiol. 2000;73(871):786-790. doi: https://doi.org/10.1259/bjr.73.871.11089474
12. Altmann, E. S., Crossingham, I., Wilson, S., & Davies, H. R. (2019). Intra-pleural fibrinolytic therapy versus placebo, or a different fibrinolytic agent, in the treatment of adult parapneumonic effusions and empyema. The Cochrane database of systematic reviews, 2019(10), CD002312. https://doi.org/10.1002/14651858.CD002312.pub4
13. Rahman NM, Maskell NA, West A, et al. Intrapleural use of tissue plasminogen activator and DNase in pleural infection. N Engl J Med. 2011;365(6):518-526. https://doi.org/10.1056/NEJMoa1012740
14. Chaddha U, Agrawal A, Feller-Kopman D, et al. Use of fibrinolytics and deoxyribonuclease in adult patients with pleural empyema: a consensus statement. Lancet Respir Med. 2021;9(9):1050-1064. doi:10.1016/S2213-2600(20)30533-6. PMID 33545086