Chest injury is a significant concern in trauma care, occurring in over 10% of all trauma admissions. These injuries vary in severity from minor rib fractures to life-threatening conditions like cardiac or tracheobronchial disruptions1. Blunt chest trauma, caused primarily by road traffic crashes and falls, is far more common than penetrating trauma, accounting for about 90% of chest injuries. Although most blunt trauma cases do not require surgical intervention, the potential for serious internal damage remains high. Mortality from chest trauma ranks second only to head injuries, underscoring the importance of rapid and accurate initial assessment. Haemorrhage is the most common cause of death in these patients, but early diagnosis and prompt management can prevent many of these fatalities2.Blunt injuries typically result from the transmission of energy to the chest wall or direct compression forces, which can affect underlying organs and structures. Penetrating chest trauma, often due to gunshot or stab wounds, leads to direct lacerations of the lungs, heart, or mediastinum. High-energy trauma—both blunt and penetrating—can also cause lung contusions and other complex injuries. Only a minority of patients with blunt chest trauma (less than 10%) and a slightly higher proportion of those with penetrating trauma (15–30%) require surgical treatment. This highlights the critical role of non-operative management, including early identification and stabilization.The term “deadly dozen” is used to describe twelve life-threatening thoracic injuries. These are split into two groups:3 six that must be identified and managed immediately during the primary survey and six that are potentially fatal and should be discovered during the secondary survey. Recognizing these conditions early requires a high index of suspicion, as symptoms may be subtle. Initial assessment of thoracic trauma follows a structured approach involving a primary survey with resuscitation of vital functions, followed by a detailed secondary survey and definitive treatment. Hypoxia remains the most serious consequence of chest trauma, and early intervention focuses on preventing or correcting oxygen deprivation.4 Many critical thoracic injuries can be managed effectively through airway control and chest decompression using a needle, finger, or chest tube. Chest radiography is an essential tool in the early evaluation of chest trauma, especially in blunt injuries, to identify pneumothorax or hemothorax. Penetrating wounds should be physically marked for imaging, and suspected mediastinal injuries warrant additional assessments like ultrasound, bronchoscopy, and contrast esophagography. Chest tube insertion is one of the most commonly performed and life-saving procedures in thoracic trauma5. It facilitates the evacuation of air or blood from the pleural cavity, prevents the development of a tension pneumothorax, re-expands the lung, and helps control pulmonary bleeding6. Indications include pneumothorax, hemothorax, pleural effusions, empyema, and other pleural pathologies7,8. However, complications such as recurrent pneumothorax after removal can increase morbidity and length of hospital stay. Current evidence remains divided on the best method for chest tube removal. While removal at end-expiration may reduce the risk of air re-entry into the pleural space, end-inspiration ensures full lung expansion, offering potential benefits in different clinical scenarios. AIM Evaluation of outcome following chest tube removal with phase of respiration in chest trauma patients.

The proposed study is a prospective cross-sectional study conducted in the Department of Surgery at Sardar Patel Medical College and Associated Group of Hospitals (AGH), Bikaner. The study population includes all patients admitted to the surgical ward with either blunt or penetrating chest trauma. The study spans a period of one year, from 1st May 2024 to 30th April 2025. Inclusion criteria for the study involve patients presenting with penetrating or blunt chest trauma and those diagnosed with pneumothorax, haemothorax, or haemopneumothorax. Exclusion criteria include non-traumatic surgical patients, patients with rib fractures not associated with pneumothorax, haemothorax, or haemopneumothorax, individuals requiring chest tube placement for medical (non-traumatic) conditions, and patients who expired prior to or during initial assessment.

RESULTS Table 1:- Age distribution Age (years) Group EE (n=63) Group EI (n=63) Intergroup p-value Number of cases % Number of cases % <20 9 14.3 1 1.6 0.008 20-30 13 20.6 16 25.4 0.525 30-40 9 14.3 12 19.1 0.473 40-50 13 20.6 14 22.2 0.828 50-60 15 23.8 11 17.5 0.379 >60 4 6.3 9 14.3 0.143 Total 63 100 63 100 Mean age(SD) years 38.71 (15.23) 41.35 (14.91) Table 1 shows, The age of patients ranged between 14-76 years. Mean age for the patients in EE group was 38.71 ± 15.23 years and EI group was 41.35 ± 14.91 years. Except for the age group <20 years (p value 0.008), the difference in distribution of cases was statistically non-significant among the two groups (p value >0.05). Table 2 :- Age group v/s Complication following chest tube removal Mean age in years (SD) Group EE (n=63) Group EI (n=63) RP RE RE+RP RP RE 40 +29.7 47+ 14.1 45+0 30.75 +9.1 55.25 +20.3 p-value (inter- group) RP – 0.559 RE – 0.443 Table 2 shows Patients of various age groups were included in our study. Mean age for the patients in EE group was 38.7115.23 years and EI group was 41.3514.91 years. However, the correlation between age group and occurrence of complications following chest tube removal did not reach level of statistical significance (p value >0.05). Table 3:- Correlation of thoracic trauma severity score (TTSS) with complications following chest tube removal. TTSS Group EE (n=63) Group EI (n=63) Inter group p-values Number of cases RP RE RE+RP Number of cases RP RE RE+RP RP RE RE+RP Grade 0 47 1 3 0 35 2 2 0 0.392 0.900 - Grade 1 16 1 4 1 28 2 2 1 0.910 0.097 0.682 Total 63 2 7 1 63 4 4 1 Table 3 shows that although higher TTSS indicates greater injury severity (range: 2–10), all patients had grade 0 or 1 TTSS with minor head injuries (GCS 15/15), and no significant correlation was found between TTSS and post–chest tube removal complications (p > 0.05), which occurred in 6.35% (grade 0) and 8.7% (grade 1) of cases. Table 4:- Duration of ICD in situ v/s Complications following chest tube removal Duration of chest tube (days) Group EE (n=63) Group EI (n=63) Inter group p- value Number of cases RP RE RE+RP Number of cases RP RE RE+RP RP RE RE+RP 1-3 days 15(23.8%) 0 2 0 7(11.1%) 0 0 0 - 0.311 - >3 days 48(76.2%) 2 5 1 56(88.9%) 4 4 1 0.516 0.554 0.912 Mean (SD) days 4.95 (2.52) 5.41 (2.25) Table 4 shows, Duration of chest tube is variable in all the patients. Maximum number of patients had duration of 4-5 days. Mean duration of chest tube in EE group was 4.95 days and 5.41 days in EI group. However, the correlation of occurrence of complications following chest tube removal and duration of chest tube in situ was statistically non significant (p value >0.05). Table 5:- Correlations between tube repositioning with complications following chest tube removal. Tube repositioning (%) Phase (% of patients) RP RE RP+RE 6 patients (4.8%) EE (50%) 0 3 0 EI (50%) 1 2 0 Inter group p-value 0.273 0.275 - Table 5 shows that 6 out of 126 patients (4.8%) required tube repositioning while the chest tube was in situ, with all EE-phase removals resulting in recurrent effusion (100%) and EI-phase removals leading to 66.7% recurrent effusion and 33.3% recurrent pneumothorax. However, the association between tube repositioning and post-removal complications was statistically non-significant (p > 0.05). 6:- Correlation of mode of chest tube removal with chest tube reinsertion Table 6:- Correlation of mode of chest tube removal with pleural aspiration post tube removal chest tube reinsertion Pleural aspiration No Yes No Yes Mode of ICD removal EE N 62 1 59 4 % 98.4% 1.6% 93.6% 6.4% EI N 60 3 61 2 % 95.2% 4.8% 96.8% 3.2% Total N 122 4 120 6 % 96.8% 3.2% 95.2% 4.8% Inter group p-value 0.309 0.563 Following chest tube removal, complications were managed conservatively or with interventions such as chest tube reinsertion (1.6% in EE and 4.8% in EI groups) and pleural aspiration (6.4% in EE and 3.2% in EI groups), with no statistically significant differences between the groups (p > 0.05). Table 7:- Correlation of mode of chest tube removal with hospital stay following chest tube removal Hospital stay after chest tube removal EE group(n=32) EI group(n=31) Mean (days) 2.59 days 2.61 days Inter group p-value 1.000 Table 7 shows, Most of the patients (50%) were discharged on the same day of chest tube removal. However, the remaining 50% patients had mean additional hospital stay of 2.60 days. However, the difference in hospital stay after chest tube removal among the two groups was statistically non-significant

In majority of studies related to chest trauma, patients in age group of 30-40 years were affected because this is the age when people stay outside and are more susceptible to trauma. The age group of patients in present study is comparable with Etoch et al.9 (1995) studied 379 patients with a mean age of 38 years. In present study the incidence of RP after chest tube removal was almost similar in both groups among the patients of blunt trauma (p value >0.05). However, among the patients of penetrating trauma incidence of recurrent pneumothorax was more in EI group. Based on mechanism of trauma the difference in occurrence of RP following chest tube removal between two groups was statistically non significant in present as well as Bell et al10 study (p value>0.05). In present study, approximately half of the patients in both the groups had a duration of 5-12 hours between traumatic event and chest tube insertion. However, based on duration between trauma and chest tube insertion, the difference in occurrence of RP following chest tube removal was statistically non-significant between two groups (p value >0.05). The occurrence of RE after chest tube removal was observed in more number of cases in which chest tubes were inserted after >48 hours of chest trauma (>50% patients of EE group and >30% patients of EI group). In present study RP following chest tube removal was seen in more number of cases having higher grades of TTSS, although statistically non significant. The occurrence of RP was comparable among the two groups when compared with relation to trauma severity score in present as well as Bell et al10study (p value >0.05). In present study chest tubes were removed when serous drainage output was <50cc in 24 hours. Mean duration of chest tube in situ in present study was comparable with other studies on thoracic trauma.However, based on duration of chest tube in situ occurrence of RP following chest tube removal was almost comparable between both the groups in both present as well as Bell et al10 study (p value >0.05). Correlation between presence of air leak and occurrence of RP following chest tube removal is given in table number 12 and was comparable among both groups (p value >0.05). However, no other study in past compared this parameter among two groups. In present study, no statistically significant correlation was found between tube repositioning and complications following chest tube removal among two groups (p value >0.05). Since no other study in past correlated tube repositioning with occurrence of RP following chest tube removal, hence we cannot compare our results with other studies. In present study, chest tubes were removed at end expiration (EE group) and at end inspiration (EI group) in 63 cases each. Chest tubes were removed by two residents (one resident pulled out the tube while other resident sealed the wound immediately after tube removal) followed by an upright chest x-ray. Overall incidence of post chest tube removal recurrent pneumothorax was 6.3% in our study that was in agreement with results of other studies (2 to 24%). In present study three patients in EE group (4.8%) and five patients in EI group (8.0%) developed RP following chest tube removal. Bell et al9 observed that RP was seen in 6% cases of EE group and 8% cases of EI group. The difference among the two groups was statistically non significant in present study as well as Bell et al10 study possibly due to small number of cases. However, number of cases developing RP in present study were almost double in EI group as compared to EE group. In present study, incidence of RE following chest tube removal has been analyzed in two groups but its occurrence does not have any correlation with tube removal in two phases of respiration. Decision for chest tube reinsertion after development of recurrent pneumothorax depends on the thickness of pneumothorax on chest x ray and patients respiratory status. The large RP as seen on chest x-ray needs chest tube reinsertion. The small RP is observed with serial chest x-ray and in case of expanding RP, chest tube reinsertion is indicated.Comparison of chest tube reinsertion rate in present study and Bell et al10 study. In present study among the patients of penetrating chest trauma, two patients developed RP following chest tube removal and both of them required chest tube reinsertion. In blunt thoracic trauma patients, RP was seen in six patients and only two of them required chest tube reinsertion. On statistical analysis the difference was statistically non significant (p value >0.05). Moreover among two of the above penetrating trauma cases, one patient required chest tube reinsertion twice indicating that penetrating trauma causes more severe lung parenchymal damage. In present study three out of 126 patients (2.4%) required ventilatory support in ICU with chest tube in situ. The chest tube was removed only when patients were off the ventilatory support and none of the patients of either groups developed RP following chest tube removal. In study of Bell et al10, 15 out of 69 patients (21.7%) requiring ventilatory support also had similar results. Thus positive pressure ventilation does not have any influence on occurrence of RP following chest tube removal provided that the chest tube is removed once patient is off the ventilatory support. However, previous study has shown that the incidence of RP following chest tube removal is 12% if chest tube is removed while patient is on ventilatory support.

The occurrence of recurrent pneumothorax following chest tube removal and its relation with two phases of respiration during chest tube removal has not been explored much in the past. Results of previous as well as present study on thoracic trauma patients suggest that chest tube removal at end of expiration leads to lower occurrence of recurrent pneumothorax following chest tube removal as compared to removal at end of inspiration. However standard practice is to remove the chest tube at end of inspiration that is contradictory to findings of present study. Hence studies with larger number of patients are required to substantiate our results.

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