Futility of Radiographs After Chest Tube Removal (FRACTR) Trial

Abstract

Background

Routine post-pull chest X-rays (CXR) are still utilized after chest tube removal in trauma patients, though their necessity in asymptomatic individuals remains debated. This study aimed to identify predictors of chest tube reinsertion and evaluate a selective, symptom-based approach to post-pull imaging.

Methods

A retrospective cohort study was conducted at a Level 1 trauma center, including 650 trauma patients who underwent chest tube placement between 2021 and 2024. Demographic and clinical variables were collected, including ICU and ventilator days, Injury Severity Score (ISS), waterseal use, and post-pull symptoms and CXR findings. Bivariate and multivariable logistic regression analyses were performed to identify predictors of reinsertion.

Results

Among 539 eligible patients and 572 chest tubes, the reinsertion rate was 10%. Post-pull symptoms were the strongest predictor of reinsertion (OR 28.38, P < 0.001), followed by shorter chest tube duration and absence of waterseal, which decreased reinsertion odds by 89.9% (OR 0.101, P = 0.008). While post-pull CXR findings were associated with reinsertion, their positive predictive value (16.9%) was markedly lower than that of clinical symptoms (56.9%). ICU stay and ventilator days were associated with reinsertion in univariate analysis but not in multivariable modeling. Patients aged ≥65 had significantly lower odds of reinsertion compared to younger patients (OR 0.26, P = 0.031).

Discussion

Clinical symptoms were the most reliable predictor of reinsertion. A selective approach guided by symptoms, waterseal use, and drainage duration may reduce unnecessary imaging. Prospective validation of this strategy is warranted.