Small versus large bore chest tube in traumatic hemothorax, hemopneumothorax, and pneumothorax: a meta-analysis of randomized controlled trials with trial sequential analysis.

backgroundThe optimal tube size for managing traumatic hemothorax, pneumothorax, or hemopneumothorax remains debated. While large-bore chest tubes (LCTs-≥ 28 Ch) are traditionally favored, emerging evidence suggests that small-caliber tubes (SCTs-≤ 14 Ch), such as pigtail catheters and small straight tubes, may offer similar efficacy with fewer complications. This study aimed to evaluate the comparative effectiveness and safety of SCTs versus LCTs from Randomized Controlled Trials (RCTs) in adult trauma patients and to assess the conclusiveness of the current evidence using trial sequential analysis (TSA).

methodsThe study was conducted according to the Cochrane recommendations, searching the PubMed, Scopus, and EMBASE datasets up to 25th March 2025 without language restrictions (PROSPERO ID: CRD420251023165). The primary outcome was treatment failure; secondary outcomes included insertion-related complications, duration of drainage, and length of hospital stay. Random effects models based on restricted maximum likelihood and Hartung-Knapp correction were developed. Sensitivity analysis was conducted to detect sources of heterogeneity. The risk of bias was assessed using the Cochrane RoB 2 tool. TSA was used to evaluate the risk of random error and to determine whether the required information size (RIS) had been reached.

resultsFour RCTs (n = 676 patients) were included. Pooled analysis showed no significant difference in failure rates between SCTs and LCTs (RR 0.95, 95% CI 0.66-1.35, I

conclusionSCTs appear to be as effective and safe as LCTs for selected trauma patients with uncomplicated thoracic injuries. However, due to limited sample size and heterogeneity across trials, current evidence is inconclusive. Larger, high-quality RCTs are warranted to confirm these findings and guide clinical practice.