Background: Chest tube malposition is the most common complication during chest tube insertion. This study aimed to compare the risk of chest tube malposition between the anterior and lateral approaches for thoracostomy performed by junior and senior residents.

Methods: This retrospective study included patients aged ≥ 20 years who exhibited primary or secondary spontaneous pneumothorax without pleural adhesion and underwent chest tube drainage performed by junior or senior residents. The study exposure involved the insertion of the chest tube in the midclavicular line (anterior approach) or the anterior or midaxillary line (lateral approach). The primary outcome was the number of malpositioned chest tubes. Multiple imputation was used for missing data. The propensity score within each imputed dataset was calculated by using the collected variables. The inverse probability of treatment weighting (IPTW) method was used to adjust for baseline confounders.

Results: IPTW analysis revealed that the estimated odds ratio for chest tube malposition in the anterior approach group (n = 34) versus the lateral approach group (n = 219) was 0.61 (95% confidence interval, 0.17–2.11).

Conclusion: In patients treated for primary or secondary pneumothorax by junior or senior residents, the risk of chest tube malposition was not significantly different between the anterior and lateral approach for thoracostomy.

This retrospective cohort study was conducted between November 2018 and March 2019 at Kameda Medical Center. The study included patients aged ≥ 20 years who were diagnosed with primary or secondary spontaneous non-tension pneumothorax without pleural adhesions and underwent chest thoracostomy performed by junior (postgraduate years 1–2) or senior (postgraduate years 3–5) residents between April 2001 and February 2019. Plain chest radiographs or CT images acquired before thoracostomy were independently evaluated by two senior pulmonology residents (AS and YT), who determined the presence or absence of pleural adhesions. The residents excluded patients via consensus if thoracostomy could be performed only by the anterior approach or the lateral approach because of dense pleural adhesions. Patients were also excluded if they were judged to have pneumothorax under mechanical ventilation or required concomitant fluid drainage before thoracotomy. The patients’ medical records provided data on the patients’ background, insertion site, and clinical course during hospitalization.

Junior and senior residents performed thoracostomy under the supervision of attending doctors. The study exposure, which involved chest tube insertion via the anterior route (interspace between the first and second ribs or the second and third ribs in the midclavicular line) or the lateral route (interspace between the fourth and fifth ribs in the anterior axillary line or midaxillary line), was determined at the discretion of the attending physician. Chest tubes were inserted anteriorly or laterally at the discretion of the attending physician.

The number of chest tube malpositions reported in the medical records was assessed as the primary outcome. Chest tube malposition was defined as clinical evidence of chest tube malfunction or failure to place the chest tube between the visceral and parietal pleural space. Malposition included lung parenchymal, mediastinal, intrafissural, intraparenchymal, or subcutaneous insertion of a chest tube, necessitating further improvements in its position or the insertion of another drainage tube. 

This dataset includes variables needed for the statistical analaysis of the primary outcome, the number of chest tube malposition. Variables are id (anonymized patient's ID), age, gender (0: female, 1: male), weight (kg), height (cm), place (place where chest tube was inserted, 0: emergency room, 1: clinic, 2: inhospital setting), department (attending doctors' department, 0: emergency department, 1: department of pulmonology, 2: department of thoracic surgery), patients' medical history (copd: chronic obstructive pulmonary disease, ild: interstitital lung disease, cancer: lung cancer or lung metastases of other type of cancer), bronchiectasis), midclavicular_approach (0: chest tube insertion laterally, 1:chest tube insertion anteriorly), death (0: not, 1: inhospital death), malposition (0:not, 1:malposition).