Routine radiography following chest tube removal in surgical patients: a systematic review

Background: Following chest tube removal, the utility of routinely obtaining a "post-pull" X-ray is unclear, and practice patterns vary widely based on institution. The objective of this review is to determine whether routine post-pull X-rays, as opposed to imaging guided by clinical assessment, leads to differences in patient-important outcomes. Methods: We performed a systematic review and meta-analyses and searched OVID Medline, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials from inception, as well as explored citations from recent systematic reviews, for studies examining adult patients admitted to a surgical service, who had chest tubes placed for any indication, and examined those who received a routine post-pull X-ray compared to those who did not. Pediatric studies were excluded. We pooled data using a random effects model and presented data as mean difference (MD) with 95% confidence intervals (CIs). We assessed risk of bias with the Risk Of Bias In Non-randomized Studies-of Interventions (ROBINS-I) tool for non-randomized studies and the Revised Cochrane Risk-of-Bias Tool for Randomized trials (ROB-II) tool for randomized trials. We assessed certainty of evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Results: Of 3,069 citations, we included 8 studies (n=3,148). Of these, only one was a randomized trial. Pooled data of non-randomized studies showed that omitting a routine post-pull X-ray had an uncertain effect on length of hospital stay [MD 3.60 days fewer (95% CI: 8.46 days fewer to 1.25 days more)], very low certainty of evidence, and had an uncertain effect on the duration of chest tube placement [MD 0.83 days fewer (95% CI: 1.65 days fewer to 0.02 days fewer)], very low certainty of evidence. Conclusions: The current data regarding the clinical utility of post-pull X-rays is poor and further high-quality studies are needed.