The first report of pigtail catheters for pleural drainage was in 1970. But, just as not all nurses are RNs, not all small catheters are “pigtail” catheters. The term refers to a curl in the distal end of the catheter inside the chest. The thinking is that the curl keeps the end-hole of the catheter off delicate tissues; pigtail catheters are also used in nephrostomies and pericardial drainage. Literature reports on pigtail catheter pleural drainage describe use for primary spontaneous pneumothorax, 1,2 sec- ondary spontaneous pneumothorax, 3,4 iatro- genic pneumothorax, 5 traumatic pneumotho- rax, 6,7 pneumothorax (etiology unspecified), 6,8-10 loculated empyema or effusion, 8,10 infective or exudative pleural effusion, 6,10 lung abscess, 8 and hemothorax. 7,10 While the authors are reporting successes, the research rais- es a number of questions. All of the studies were retrospective. When traditional chest tubes were compared with pigtail catheters, tubes were selected by attending physician prefer- ence with no standard guidelines. Surgeons inserted chest tubes; intensivists, pulmonologists, and emergency medicine physicians inserted catheters. There is no way to know if posi- tive outcomes are related to the pigtail or the small size of the catheter. Pigtail catheters are inserted percutaneously using Seldinger technique. The pleura is initially punctured with a hollow needle trocar attached to a syringe; air or fluid is aspirated to confirm placement. The syringe is removed and a guidewire advanced through the needle lumen. The guidewire stays in place while the needle is removed and a dilator is passed over the guidewire to enlarge the opening through which the catheter will be placed. Next, the dilator is removed, the pigtail is uncoiled, and the catheter is threaded over the guidewire and into the pleural space. Finally, the guidewire is removed as the distal end of the catheter curls inside the chest. 7,11 Since this technique is similar to that used for placing central venous catheters and pacemak- er leads, intensivists and pulmonologists are much more likely to perform the procedure at the bedside. Researchers note careful technique is essential to place the catheter above the sixth inter- costal space to avoid the diaphragm, keep the needle perpendicular to the rib and advance it only until the parietal pleura is punctured, insert only over the rib – never under (to avoid vessels and nerves), and to be particu- larly alert to the potential for kinking the wire or catheter. 7,11 The catheter is then con- nected to a drainage device. Some studies did not speci- fy the device, 6,7,11 others connected the catheter to a traditional drain, 5,8,9 one to a drainage bag, 10 and the rest used a “Heimlich valve bag.” 1,3,4 Ideally, small tubes are connected to small devices that weigh less than traditional drains, put less traction on the catheter, and allow for patient mobility. The original small device is the Heimlich valve, but the lack of a collection chamber for drainage has led to much improvisation attaching various drainage bags to the distal end of the device. While a bag contains the fluid, air can expand a sealed bag like a balloon. Leaving an opening at the top of the bag vents the air, but drainage can spill out of any opening without very careful positioning. It’s important to note that the Heimlich valve is not sold with a collection device. It’s all “off label” use. Two newer devices not mentioned in the literature are the Pneumostat ™ and the Express ™ Mini 500. The Pneumostat has a built-in one-way valve, a 30mL chamber to collect fluid, and an air leak indicator that makes it a significant advantage over the Heimlich valve. 2 The Express Mini 500 is a miniature chest drain designed for higher volume fluid drainage; it has an integrated dry suction regulator that can be attached to wall vacuum. Both devices allow clinicians to maintain standard precautions easily, unlike the Heimlich valve. In recent years, there has been a trend toward smaller tubes for a number of drainage tasks. Smaller tubes are less disrup- tive to tissue and are less likely to impinge on nerves, resulting in less pain. The distance between ribs in an adult is about 9mm (5th intercostal space, midaxillary line). 11 Compare that potential opening with a 32F chest tube at 10.7mm, a 24F tube at 8mm and an 8F pigtail catheter at 2.7mm. A 32F chest tube is larger than the space available, clearly explaining why large chest tubes are painful and why smaller tubes hurt less. However, small tubes are less efficient evacuating the chest. Decreasing the internal diameter of a drainage tube from 8mm (24F) to 4mm (12F) decreases flow from 30LPM to 5LPM. 12 A study testing flow rate through commercially available tubes found a range of 1.5LPM to 3.3LPM at 8F and -10cmH 2 O and 17.5LPM through a 24F catheter. 13 Smaller tubes are more likely to malfunction Patient Selection Key for Pigtail Catheters Clinical Update is edited by Patricia Carroll, MS, RN-BC, CEN, RRT, and supported by an educational grant from Atrium Medical Corporation. Fall 2012 Continued on page 2 Pigtail catheter inside chest. A intercostal muscle B rib. C distal end of catheter with curl Vessels and nerves are inferior to rib margin C B A
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The first report of pigtail catheters for pleural drainage was in1970. But, just as not all nurses are RNs, not all small cathetersare “pigtail” catheters. The term refers to a curl in the distal endof the catheter inside the chest. The thinking is that the curlkeeps the end-hole of the catheter off delicate tissues; pigtailcatheters are also used in nephrostomies and pericardialdrainage.
Literature reports onpigtail catheter pleuraldrainage describe usefor primary spontaneouspneumothorax,1,2 sec-ondary spontaneouspneumothorax,3,4 iatro-genic pneumothorax,5traumatic pneumotho-rax,6,7 pneumothorax(etiology unspecified),6,8-10 loculated empyema or effusion,8,10
infective or exudative pleural effusion,6,10 lung abscess,8 andhemothorax.7,10
While the authors are reporting successes, the research rais-es a number of questions. All of the studies were retrospective.When traditional chest tubes were compared with pigtailcatheters, tubes were selected by attending physician prefer-ence with no standard guidelines. Surgeons inserted chesttubes; intensivists, pulmonologists, and emergency medicinephysicians inserted catheters. There is no way to know if posi-tive outcomes are related to the pigtail or the small size of thecatheter.
Pigtail catheters are inserted percutaneously using Seldingertechnique. The pleura is initially punctured with a hollow needletrocar attached to a syringe; air or fluid is aspirated to confirmplacement. The syringe is removed and a guidewire advancedthrough the needle lumen. The guidewire stays in place whilethe needle is removed and a dilator is passed over the guidewireto enlarge the opening through which the catheter will be placed.Next, the dilator is removed, the pigtail is uncoiled, and thecatheter is threaded over the guidewire and into the pleuralspace. Finally, the guidewire is removed as the distal end of thecatheter curls inside the chest.7,11 Since this technique is similarto that used for placing central venous catheters and pacemak-er leads, intensivists and pulmonologists are much more likely toperform the procedure at the bedside. Researchers note carefultechnique is essential to place the catheter above the sixth inter-costal space to avoid the diaphragm, keep the needleperpendicular to the rib and advance it only until the parietal
pleura is punctured, insertonly over the rib – neverunder (to avoid vessels andnerves), and to be particu-larly alert to the potential forkinking the wire orcatheter.7,11
The catheter is then con-nected to a drainage device.Some studies did not speci-fy the device,6,7,11 othersconnected the catheter to a traditional drain,5,8,9 one to adrainage bag,10 and the rest used a “Heimlich valve bag.”1,3,4
Ideally, small tubes are connected to small devices that weighless than traditional drains, put less traction on the catheter, andallow for patient mobility. The original small device is theHeimlich valve, but the lack of a collection chamber for drainagehas led to much improvisation attaching various drainage bagsto the distal end of the device. While a bag contains the fluid, aircan expand a sealed bag like a balloon. Leaving an opening atthe top of the bag vents the air, but drainage can spill out of anyopening without very careful positioning. It’s important to notethat the Heimlich valve is not sold with a collection device. It’s all“off label” use.
Two newer devices not mentioned in the literature are thePneumostat™ and the Express™ Mini 500. The Pneumostat hasa built-in one-way valve, a 30mL chamber to collect fluid, and anair leak indicator that makes it a significant advantage over theHeimlich valve.2 The Express Mini 500 is a miniature chest draindesigned for higher volume fluid drainage; it has an integrateddry suction regulator that can be attached to wall vacuum. Bothdevices allow clinicians to maintain standard precautions easily,unlike the Heimlich valve.
In recent years, there has been a trend toward smaller tubesfor a number of drainage tasks. Smaller tubes are less disrup-tive to tissue and are less likely to impinge on nerves, resultingin less pain. The distance between ribs in an adult is about 9mm(5th intercostal space, midaxillary line).11 Compare that potentialopening with a 32F chest tube at 10.7mm, a 24F tube at 8mmand an 8F pigtail catheter at 2.7mm. A 32F chest tube is largerthan the space available, clearly explaining why large chesttubes are painful and why smaller tubes hurt less. However,small tubes are less efficient evacuating the chest. Decreasingthe internal diameter of a drainage tube from 8mm (24F) to 4mm(12F) decreases flow from 30LPM to 5LPM.12 A study testingflow rate through commercially available tubes found a range of1.5LPM to 3.3LPM at 8F and -10cmH2O and 17.5LPM througha 24F catheter.13 Smaller tubes are more likely to malfunction
Patient Selection Key for Pigtail Catheters
Clinical Update is edited by Patricia Carroll, MS, RN-BC, CEN, RRT, andsupported by an educational grant from Atrium Medical Corporation.
Fall 2012
Continued on page 2
Pigtail catheter inside chest. A intercostal muscle B rib. C distal end of catheter with curl
Vessels and nerves are inferior to rib margin
C
B
A
In the LiteratureMovin’ on Up!
The current issue of Orthopaedic Nursing has an incrediblydetailed description of a progressive mobility activity protocol forcritically ill patients. Not only does the author describe risks ofimmobility, she also synthesizes the best evidence, provides stan-dards of practice and principles of planning a change in practice.The article also provides a care plan and documentation flow sheetthat will make adopting this protocol even easier for other facilities.This is don’t miss research for anyone who wants to enhance a crit-ical care mobility program. Source: King L: Developing a progressive mobility activity protocol. OrthopaedicNursing 2012;31(5):253-262. PubMed Citation
Who Speaks for the Voiceless?Assessing symptoms in critically ill patients unable to communi-
cate has always been challenging. A study in the current issue ofCritical Care Medicine compared proxy assessments by familymembers, nurses, and physicians with patient reports in twodomains: intensity and distress. The assessments were pain, tired-ness, SOB, restlessness, anxiety, sadness, hunger, fear, thirst andconfusion. Family members’ assessments were closer in agree-ment with patients’ ratings than those of clinicians, indicating familymembers may be the most effective proxies when patients areunable to communicate. Source: Puntillo KA et al: Challenge of assessing symptoms in seriously ill inten-sive care unit patients: can proxy reporters help? Critical Care Medicine2012;40(10):2760-2767. PubMed Citation
Who’s Best to Lead Evidence-Based Practice?Researchers in Sweden present a new measure of self-assess-
ment of capabilities in evidence-based practice and their correlationto application of EPB and research use in RNs at year 2 of practice.Nurses scored six items on a scale of 0 (cannot) to 10 (definitelycan) relating how confident they were performing those six steps ofthe EBP process. Nurses with highest scores used research morethan twice as often. While the tool needs additional validity testing, itis a simple, promising tool to identify EBP champions.Source: Wallin L et al: Capability beliefs regarding evidence-based practice areassociated with application of EBP and research use: validation of a new meas-ure. Worldviews on Evidence-Based Nursing 2012;9(3):139-148. PubMedCitation
Your Government at WorkIt can be a challenge to find information such as ingre-dients for OTC meds. Not any longer! The NationalLibrary of Medicine has set up DailyMed, a user-friend-ly database of OTC and prescription labeling. You canaccess online, or download the database for local use.http://dailymed.nlm.nih.gov/dailymed
Did you know there are specific nursing provisions in thePatient Protection and Affordability Care Act? The AARPPolicy Institute has compiled these in one document.From grants to scholarships, to loan forgiveness programsand workforce development demonstration projects,they’re all here. This link opens a PDF document.http://tinyurl.com/8s8zpcz
The CDC’s Division for Heart Disease and StrokePrevention has created the Interactive Atlas of HeartDisease and Stroke, a mapping tool that lets youexplore geographic disparities in the burden of cardio-vascular disease at state and county levels. You cancreate county-level maps of 9 different disease out-comes by race, ethnicity and age group and you canoverlay these maps with locations of health care facili-ties. This is ideal for monitoring trends, settingresearch priorities and planning patient services inyour community.http://apps.nccd.cdc.gov/dhdspatlas
Fall 2012
and be externally compressed, particularly if the tube is soft.6Kinking is also a risk with small, soft tubes.
As with most things in healthcare, using a pigtail catheter forchest drainage involves trade-offs. They are easier to insert, dis-rupt less tissue, are less painful, and usually placed more quickly.On the other hand, they are more likely to obstruct, can easilykink, allow significantly less flow out of the chest and may notwork for thick fluid drainage. The key to successful use of thesecatheters is careful patient selection before catheter placement,appropriate chest drain devices, and vigilant nursing care.Targeted nursing assessments will promptly identify respiratorychanges that indicate tube or system malfunction.Sources1. Kuo HC, YJ Lin, CF Huang, et al.: Small-bore pigtail catheters for the treatment of pri-mary spontaneous pneumothorax in young adolescents. Emerg Med J 2012 ePub aheadof print;1doi: 0.1136/emermed-2011-200986. PubMed Citation2. Marquette CH, A Marx, S Leroy, et al.: Simplified stepwise management of primaryspontaneous pneumothorax: a pilot study. Eur Respir J 2006;27(3):470-476.PubMed Citation
3. Tsai WK, W Chen, JC Lee, et al.: Pigtail catheters vs large-bore chest tubes for man-agement of secondary spontaneous pneumothoraces in adults. Am J Emerg Med2006;24(7):795-800. PubMed Citation4. Chen CH, WC Liao, YH Liu, et al.: Secondary spontaneous pneumothorax: whichassociated conditions benefit from pigtail catheter treatment? Am J Emerg Med2012;30(1):45-50. PubMed Citation5. Noh TO, KM Ryu: Comparative study for the efficacy of small bore catheter in thepatients with iatrogenic pneumothorax. Korean J Thorac Cardiovasc Surg2011;44(6):418-422. 3270284. PubMed Citation6. Aziz F, S Penupolu, D Flores: Efficacy of percutaneous pigtail catheters for thoracos-tomy at the bedside. Journal of Thoracic Disease 2012;4(3):292-295. PubMed Citation7. Kulvatunyou N, A Vijayasekaran, A Hansen, et al.: Two-year experience of using pig-tail catheters to treat traumatic pneumothorax: a changing trend. J Trauma2011;71(5):1104-1107; discussion 1107. PubMed Citation8. Crouch JD, BA Keagy, DJ Delany: "Pigtail" catheter drainage in thoracic surgery. AmRev Respir Dis Jul 1987;136(1):174-175. PubMed Citation9. Lin YC, CY Tu, SJ Liang, et al.: Pigtail catheter for the management of pneumotho-rax in mechanically ventilated patients. Am J Emerg Med 2010;28(4):466-471. PubMed Citation10.Liu YH, YC Lin, SJ Liang, et al.: Ultrasound-guided pigtail catheters for drainage ofvarious pleural diseases. Am J Emerg Med 2010;28(8):915-921. PubMed Citation11. Gammie JS, MC Banks, CR Fuhrman, et al.: The pigtail catheter for pleural drainage:a less invasive alternative to tube thoracostomy. Journal of the Society ofLaparoendoscopic Surgery 1999;3:57-61. PubMed Citation12.Kam AC, M O'Brien, PCA Kam: Pleural drainage systems. Anaesthesia1993;48:154-161. PubMed Citation13.Baumann MH, PB Patel, CW Roney, MF Petrini: Comparison of function of commer-cially available pleural drainage units and catheters. Chest 2003;123(6):1878-1886.PubMed Citation
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