RESULTS
A total of 375 studies were retrieved through our search, and 80
duplicates were removed. The titles and abstracts of the remaining 295
studies were screened to identify potentially eligible 22 studies. After
the full-text screening, 18 studies were included in the systematic
review. Eleven studies were conducted in the United States of
America1–3,7,10–16,
four studies in the United
Kingdom17–20,
one in the
Netherlands5,
one in
Germany21and one in
Iran6(Table 1). No other studies were identified through manual screening of
references of the included studies and relevant reviews. PRISMA flow
diagram is demonstrated in Figure 1. Adult patients refer to patients at
least 18 years of age, and paediatric patients refer to patients under
the age of 18 in the studies. Re-intervention is defined as the
re-insertion of a chest drain.
Cardiac surgery adult
patients
One simple randomised
trial6,
three prospective cohort
studies5,11,19and one retrospective cohort
study18evaluated the efficacy of routine chest X-rays constituting a total of
2,080 adult patients undergoing cardiac surgery procedures, which
includes coronary artery bypass grafting (CABG), valve surgery and
atrial septal defect repair, either as isolated procedures or in
combination. The mean duration of chest drain before removal is 1.4-1.8
days11,18,19,
and a routine chest X-ray is obtained within 3-4 hours after the
removal.6,19
If a chest X-ray is obtained after the removal, the incidence of
pneumothorax ranges from 1.3-9.3% with up to 1.3% of patients
developing respiratory symptoms or haemodynamic changes and
re-intervention was required in 0.5-1.3% of the
patients.5,6,11,18,19If no routine chest X-ray was performed after the drain removal,
5.0-11.8% of the patients developed respiratory symptoms or
haemodynamic changes, of which 0.7-2.5% would require
re-intervention.6,18
Cardiac surgery paediatric
patients
Two prospective cohort
studies10,20and two retrospective cohort
studies7,14have examined the incidence of pneumothorax and the efficacy of chest
X-rays after the chest drain removal. It includes a total of 12,171
paediatric patients undergoing congenital cardiac surgery operations.
The mean age of the patients ranges from 0.2-2.7 years. The mean
duration of chest drain varies from 1-6.4 days after the procedure, and
a chest X-ray is performed within 2-6 hours after the removal of the
drain.7,10,14,20
The incidence of pneumothorax after chest drain removal is 0.21% in a
study with 11,651
patients7and goes as high as 13.6% in other
studies.10,14,20Clinical symptoms developed in 0.1-1.87% of the patients, and 0.1-1.6%
of patients would eventually undergo re-intervention for the
pneumothorax.7,14
Thoracic surgery adult
patients
Three prospective
studies15,17,21and two retrospective
studies1,2including 921 patients explored the effectiveness of routine chest
X-rays in adult patients undergoing thoracic surgical procedures, which
include both video-assisted thoracoscopy (VATS) and open surgery. The
patients have a mean age of 60-64 years in the studies and had the chest
drains for an average duration ranging from 1-4 days. A chest X-ray is
usually performed 2-4 hours after the removal of the chest
drain.1
The incidence of pneumothorax on the chest X-ray after removal of the
drain varies greatly from 4 to
48%.1,2,15,17,21Nonetheless, only up to 0.5% of patients need a subsequent intervention
after the positive radiographic
findings.1,2,17The incidence of pneumothorax in asymptomatic patients is approximately
32.8%, but none of the patients required re-intervention. They only had
clinical observation and repeated the chest
X-rays.1
Thoracic surgery paediatric
patients
Four retrospective studies with a total of 708 paediatric patients
investigated the necessity of performing routine chest X-rays after the
removal of chest
drains.3,12,13,16The mean age of patients in the studies ranges from 7.5 to 9.4 years.
The patients underwent various thoracic surgical procedures including
VATS and open surgeries. The average length of the chest drain is
3.7-7.2 days before removal, and the chest X-rays are obtained within
2-6 hours after the removal of the drain.
In the post-drain removal chest X-rays, the incidence of pneumothorax is
3.1-3.9%3,12with a re-intervention rate is
0.7-1.7%.12,13,16Clinical symptoms were present in all patients who required
re-intervention. In asymptomatic patients, the incidence of pneumothorax
is
1.8%13,
of which 0.4-0.9% of the asymptomatic patients would undergo further
re-intervention.13,16
Bedside ultrasound versus chest X-ray after removal of chest
drain
There are two prospective observational studies with combined 173
patients, which evaluated the role of bedside ultrasound in comparison
to using chest X-ray after removal of a chest drain to detect
pneumothorax, predominantly in the thoracic adult surgical
population.15,21The overall sensitivity of the bedside ultrasound is 32%, however, the
sensitivity is increased to 100% in detecting pneumothoraces of 3 cm or
larger, and the specificity is
85%.21There is a strong association between ultrasound and chest X-ray with a
therapeutic agreement of
97%.21There is perfect agreement between the two methods with a 𝛋 statistics
value of
1.000.15