Highlights
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Developed an improvised chest tube drainage system using locally available materials for conflict zones.
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Achieved 90 % lung re-expansion within 72 h, comparable to conventional systems.
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Recorded low complication rates, including empyema (12 %) and subcutaneous emphysema (20 %).
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Demonstrated cost-effectiveness and adaptability in resource-limited settings.
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Offers a scalable model for emergency thoracic care in low-resource and disaster environments.
Keywords: Improvised chest tube drainage, Thoracic injuries, Resource-limited settings, Conflict zones, Emergency care, Innovation in surgery
Abstract
Background
Thoracic injuries pose a challenge in conflict zones, where disrupted healthcare infrastructure and supply shortages limit access to conventional chest tube drainage (CTD) systems. This study evaluates the safety and efficacy of an improvised CTD system as a viable alternative in resource-limited settings in Sudan.
Methods
A prospective, single-center analytical cohort study was conducted at a tertiary hospital in Sudan from June to December 2023. A total of 120 adult patients (aged 18–70 years) requiring CTD for thoracic injuries were included. The improvised CTD system consisted of a radiopaque nasogastric (NG) tube and a repurposed 1.5-liter plastic water bottle as an underwater seal. Clinical outcomes, complications, and patient satisfaction were assessed. Serial imaging at baseline and 24-hour intervals evaluated lung re-expansion and drainage efficacy. Data were analyzed using SPSS, with p < 0.05 considered significant.
Results
Lung re-expansion was achieved in 90 % (N = 108) of patients within 72 h. Complications included atelectasis in 15 % (N = 18), subcutaneous emphysema in 20 % (N = 24), and empyema in 12 % (N = 14). Tube repositioning was required in 25 % (N = 30) of cases, and obstruction occurred in 10 % (N = 12). The mean hospital stay was 6.5 days, and mortality was 5 % (N = 6). Smoking status, age, and injury type significantly predicted complications. Patient satisfaction was high, with 85 % (N = 102) rating their experience as satisfactory.
Conclusions
The improvised CTD system is a safe, effective, and cost-efficient alternative for managing thoracic emergencies in conflict settings. Its adaptability addresses critical gaps in emergency care, offering a scalable model for humanitarian crises worldwide.
1. Introduction
1.1. Background and rationale
Since gaining independence in 1956, Sudan has faced ongoing armed conflicts and political instability, leading to severe disruptions in its healthcare infrastructure (1,2). These conflicts have resulted in the destruction of medical facilities, disrupted supply chains, and forced the migration of healthcare professionals (3). The World Health Organization (WHO) has warned of escalating mortality due to the collapse of essential healthcare services (4). In this context, access to surgical and emergency care remains critically limited, necessitating innovative solutions to address the gaps in life-saving interventions.
1.2. Importance of chest tube (CTD)
CTD is essential for managing thoracic injuries, which are common in conflict zones. It facilitates the evacuation of air and fluid from the pleural cavity, restoring negative intrathoracic pressure necessary for lung re-expansion and normal ventilation (5). CTD is most commonly employed in the management of pneumothorax, hemothorax, pleural effusions, empyema, and flail chest, all of which necessitate urgent intervention to prevent respiratory compromise and hemodynamic instability (6). The frequent unavailability of conventional drainage systems in these settings underscores the need for alternative solutions.
1.3. Current practices and limitations
Standard CTD systems typically consist of a tube connected to a drainage container that utilizes an underwater seal to facilitate air or fluid evacuation and lung re-expansion (5,7). However, in Sudan's conflict zones, the deployment of these systems is hindered by persistent supply shortages, logistical constraints, and damaged infrastructure (3). The scarcity of essential medical supplies, including chest tubes and sterile containers, forces healthcare providers to seek alternative methods using locally available materials. Surgical teams in Sudan adopted innovative approaches to overcome these challenges.
1.4. Objectives of the study
This study aims to assess the safety and efficacy of an improvised CTD system as an alternative to conventional methods in conflict zones in Sudan. Additionally, it seeks to evaluate resource utilization, including cost and time efficiency, and to identify complications associated with the use of this improvised system.
1.5. Significance of the study
Validating the safety and effectiveness of an improvised CTD system could significantly enhance thoracic emergency care in resource-limited settings. By providing a cost-effective alternative, this study may reduce morbidity and mortality associated with thoracic injuries in conflict zones. The findings could inform future medical practices and policies, especially during disasters and pandemics where resources are significantly constrained. Additionally, insights gained may contribute to broader discussions on innovative solutions for surgical and trauma care in humanitarian crises.
2. Material and methods
2.1. Study design and setting
This prospective analytical cohort study was conducted at a tertiary care hospital in Sudan, which serves as a key evacuation center for injured individuals (Fig. 1). The study employed a pragmatic observational approach to assess real-world outcomes and was designed to evaluate the safety and efficacy of an improvised CTD system in a conflict-affected setting (8). The system was developed through a multidisciplinary approach, involving thoracic surgeons, emergency medicine specialists, and biomedical engineers, and was assessed for safety, functional reliability, and feasibility. The study commenced on June 1, 2023, and concluded on December 1, 2023.
Fig. 1.
Conflict Displacement in Sudan with Focus on Wad Madani — The Study Area and First-Response Center.
2.2. Patient selection
2.2.1. Sample size and sampling method
A total of 120 patients were enrolled using convenience sampling, based on the availability of eligible cases during the study period. Given the constraints of the conflict setting, a randomized trial was not feasible. The sample size was determined based on patient volume at the study center and logistical constraints rather than a formal power calculation, which is a limitation.
2.2.2. Inclusion and exclusion criteria
Inclusion Criteria
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Adults aged 18 to 70 years.
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Patients presenting with isolated thoracic injuries requiring CTD due to blunt or penetrating trauma.
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Clinically stable patients able to undergo chest X-ray or lung re-expansion assessment.
Exclusion Criteria:
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Pre-existing severe lung disease (e.g., advanced Chronic obstructive pulmonary disease (COPD), Congestive heart failure (CHF), tuberculosis) that could impact drainage outcomes.
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Patients with major additional injuries or a history of prior chest surgery that might interfere with intervention success.
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Individuals unable to provide informed consent.
2.3. Intervention protocol
2.3.1. Description of the improvised CTD system
The improvised CTD system utilized a radiopaque polyurethane nasogastric (NG) tube, chosen for its biocompatibility, radiographic visibility, and flexibility, minimizing pleural tissue irritation (9). The specifications of the NG tube were as follows:
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External diameter: 4 mm, Internal diameter: 3 mm.
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Length: 120 cm, ensuring adequate placement and manageable handling.
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The distal 15 cm of the tube featured 20 evenly spaced pores, each measuring 2 mm in diameter, designed to ensure efficient drainage and minimize the risk of blockage from clots or fibrinous material. Clear manual depth markings, drawn with a permanent marker at 5 cm, 10 cm, and 15 cm from the distal tip, indicated safe and accurate insertion depths at the skin entry point.
The NG tube was pre-sterilized by the manufacturer, while the 1.5-liter plastic water bottle, used as an underwater seal, was sterilized with ethylene oxide and hermetically sealed until deployment.
2.3.2. Assembly and use of the improvised CTD system
The system was assembled by:
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Using two NG tubes: one functioning as the chest tube and the second as the drainage tube connected to the water bottle.
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Connecting the proximal end of the drainage NG tube to a plastic bottle, which was manually marked at 200 ml intervals for fluid measurement.
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Pre-filling the bottle with 400 ml of normal saline to act as an underwater seal.
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Inserting a sterile, stick-like support (such as a sterile plastic straw or rigid sterile rod) inside the drainage tube within the bottle to prevent kinking and ensure uninterrupted drainage.
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Drilling a precisely sized hole in the bottle cap and securing the tube connection with silicone sealant and adhesive tape to maintain an airtight seal and facilitate proper lung re-expansion (Fig. 2).
Fig. 2.
Improvised CTD system in a patient with right-sided hemothorax.
The yellow arrow indicates the CTD site with skin fixation.
The green arrow shows the improvised chest tube (NG) placed in the pleural cavity.
The blue arrow demonstrates the drainage pathway to the water-seal bottle with visible blood drainage.
The black arrow highlights the airtight seal around the tube entry on the bottle cap secured with plaster.
The red arrow shows approximately 1500 ml of collected blood in the improvised water-seal drainage bottle.
2.3.3. Chest tube insertion procedure
Chest tube insertion was performed under strict aseptic conditions by six senior registrars, each with a minimum of four years of experience in chest tube placement and thoracic trauma management. Standardized protocols were followed to ensure consistency and procedural validation. Tube placement and function were confirmed immediately post-insertion via chest X-ray, utilizing the NG tube's radiopaque.
2.4. Monitoring and outcome assessment
2.4.1. Imaging and radiological evaluation
Serial radiological assessments were performed at 24-hour intervals to monitor lung re-expansion, respiratory improvement, and drainage volume. Blinded evaluation by two independent radiologists minimized observer bias, with any discrepancies resolved by a third reviewer.
2.4.2. Diagnostic criteria
Diagnoses were primarily based on clinical assessment and discharge records. For parapneumonic effusions, pleural fluid pH <7.2 (per Light's criteria) was used to classify cases as empyema (10). All final diagnoses were reviewed and confirmed by a surgery consultant before patient discharge.
2.4.3. Standardized criteria for lung re-expansion and tube removal
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Lung re-expansion was defined as complete apposition of the visceral and parietal pleura and resolution of pneumothorax or pleural fluid accumulation.
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●Criteria for tube removal included:
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○Drainage below 50 ml in 24 h.
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○Radiological confirmation of lung re-expansion.
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○Absence of air leaks.
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2.4.4. Data collection
Data were collected using a structured checklist, covering:
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Patient demographics, injury mechanisms, clinical outcomes, complications, hospital stay, recurrence rates, and three-month follow-ups.
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Patient satisfaction, assessed through a 5-point Likert scale.
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To ensure accuracy and minimize reporting errors, data were cross verified, with discrepancies resolved by supervising consultants.
2.5. Statistical analysis
2.5.1. Outcome measures
The primary outcome was lung re-expansion within 72 h, confirmed via chest imaging. Secondary outcomes included infection rates, hospital length of stay, complication rates, and patient satisfaction scores assessed through a 3-month follow-up via phone call. Outcome assessors were blinded to the intervention details to minimize bias.
2.5.2. Data analysis approach
Statistical analysis was performed using IBM SPSS Statistics (Version 25). Categorical variables were analyzed using Chi-square tests. Continuous variables were assessed using one-way analysis of variance (ANOVA) for comparisons across multiple groups or Student's t-test for two-group comparisons, based on data distribution. The association between in-hospital stay and clinical outcomes (residual hemothorax, prolonged air leakage >5 days, and necessity for second drainage insertion) was evaluated using ANOVA. Patients were categorized based on the presence or absence of these complications as explanatory variables, and the length of hospital stay was the continuous outcome variable. Kaplan-Meier survival analysis was conducted to assess 30-day mortality outcomes. Multivariate logistic regression was used to adjust for potential confounders, including age, sex, smoking status, and injury severity. Confidence intervals (CIs) and adjusted odds ratios (AORs) were reported for key findings, with Bonferroni correction applied to adjust for multiple comparisons. Currency conversions from Sudanese Pounds (SDG) to United States Dollars (USD) were calculated using the official exchange rate provided by the Central Bank of Sudan as of January 1, 2023, with 1 USD equivalent to 580 SDG. (11).
2.6. Ethical considerations
The study received ethical approval from the Wad Madani Teaching Hospital Institutional Review Board (Approval No: WDMAD-2023–22) on April 3, 2023. Informed consent was obtained from all participants, with assurances of confidentiality and voluntary participation. Consent was also obtained for the use of clinical images with no identifying data. Data were anonymized and stored securely in compliance with the Declaration of Helsinki. The study was registered at ClinicalTrials.gov (NCT06683976) to ensure transparency.
3. Results
3.1. Baseline characteristics of study participants
The study cohort (N = 120) was predominantly male, with 60 % (N = 72) being male, 40 % (N = 48) middle-aged (41–60 years), and 75 % (N = 90) civilian. Most patients had a normal Body Mass Index (BMI) 45 % (N = 54) and were non-smokers 65 % (N = 78). Notably, 65 % (N = 78) of patients presented to the hospital within 3 h of injury, highlighting effective evacuation efforts in the conflict zone (Table 1).
Table 1.
Demographic Data of Study Participants.
| Variables | Sub Variables | Total | Percentage (%) |
|---|---|---|---|
| Age | - 18–40 | 36 | 30 % |
| - 41–60 | 48 | 40 % | |
| - Over 60 | 24 | 20 % | |
| Gender | - Male | 72 | 60 % |
| - Female | 48 | 40 % | |
| BMI | - Underweight (<18.5) | 6 | 5 % |
| - Normal (18.5–24.9) | 54 | 45 % | |
| - Overweight (25–29.9) | 42 | 35 % | |
| - Obese (≥30) | 18 | 15 % | |
| Smoking Status | - Non-smoker | 78 | 65 % |
| - Former smoker | 24 | 20 % | |
| - Current smoker | 18 | 15 % | |
| Civilian or Military | - Civilian | 90 | 75 % |
| - Military | 30 | 25 % | |
| Time from Injury to Hospital Presentation | - <1 h | 30 | 25 % |
| - 1–3 h | 48 | 40 % | |
| - >3 h | 42 | 35 % |
3.2. Patterns of thoracic trauma analysis
Penetrating trauma 42.5 % (N = 51) was the most common injury mechanism, primarily from gunshot wounds 27.5 % (N = 33), followed by blunt trauma 36.7 % (N = 44), with explosive devices being the leading cause 26.7 % (N = 32). Mixed injuries accounted for 6.7 % (N = 8) of cases (Fig. 3).
Fig. 3.
Distribution of Patients by Mechanism of Injury.
3.3. Distribution of chest injuries and trauma sites
Pneumothorax 40 % (N = 48) was the most common injury managed with the improvised CTD, followed by hemothorax 32.5 % (N = 39) and hemopneumothorax 20 % (N = 24). Trauma distribution was as follows: right side 36.7 % (N = 44), left side 35 % (N = 42), and bilateral involvement in 28.3 % (N = 34). Rare injuries, including chylothorax, esophageal injury, and flail chest, accounted for 7.5 % (N = 9), demonstrating the wide applicability of the improvised system (Fig. 4). Thoracotomy was required in 3.3 % (N = 4) of cases due to major bronchial injury, ongoing massive hemothorax, and chylothorax. Three patients died postoperatively, while one chylothorax case survived after thoracic duct ligation. Two additional patients with bilateral flail chest injuries died due to ICU bed unavailability. Overall, 95 % (N = 114) of patients were successfully managed with the improvised system. One esophageal injury was managed conservatively with full recovery (Table 2).
Fig. 4.
Distribution of Chest Injury Types and Sites of Trauma with Improvised CTD system Utilization.
Table 2.
Indications for Escalation to Thoracotomy, Associated Complications, and 30-Day Outcomes in Patients Managed with Improvised CTD.
| Reason for Escalation to Thoracotomy | Number of Cases (N) | Percentage (%) | Associated Outcome |
|---|---|---|---|
| Continuous active bubbling in the underwater seal (suggestive of major bronchial injury) | 1 | 0.8 % | Death on the 5th postoperative day (patient had pneumothorax) |
| Ongoing hemothorax drainage (∼400 ml/hour for two consecutive hours after CTD insertion) | 1 | 0.8 % | Death on the 2nd postoperative day (patient had massive hemothorax) |
| Massive subcutaneous emphysema extending to the neck and thighs (indicating major bronchial injury) | 1 | 0.8 % | Death on the 7th postoperative day (patient had pneumothorax) |
| Chylothorax confirmed by fluid analysis | 1 | 0.8 % | Survived; thoracotomy with thoracic duct ligation performed |
| Total escalation to thoracotomy | 4 | 3.3 % | 3 deaths, 1 survival |
| Successfully managed with improvised CTD alone | 114 | 95 % | Discharged without the need for thoracotomy |
| Esophageal injury diagnosed by the presence of food particles in chest drain fluid | 1 (managed conservatively with gastrostomy tube) | — | Survived; spontaneous resolution without surgical intervention |
| Bilateral flail chest injuries (unable to escalate due to ICU bed unavailability) | 2 | — | Death due to lack of ICU availability |
3.4. Clinical outcomes of the improvised CTD system
The improvised CTD system demonstrated a low complication rate, with residual hemothorax in 20 % (N = 24), residual pneumothorax in 12 % (N = 14), and second drainage insertion in 10 % (N = 12); none of these were statistically significant (all p > 0.05). However, the mean hospital stay was significantly longer in patients with complications such as residual hemothorax, prolonged air leakage, or the need for second drainage insertion (mean 6.5 days, SD 2.3; ANOVA, p = 0.02). Specifically, patients who developed complications (residual hemothorax, prolonged air leakage >5 days, or required second drainage insertion) had a significantly longer hospital stay compared to those without complications (ANOVA, p = 0.02). The 30-day mortality rate was 5 % (N = 6), and 90-day readmissions for effusion 7 % (N = 8) and pneumothorax 5 % (N = 6) were not statistically significant (Table 3).
Table 3.
Clinical Outcomes and Statistical Analysis of Patients Managed with the Improvised Chest Tube Drainage System.
| Outcome | Rate/Measure | Statistical Analysis |
|---|---|---|
| Residual hemothorax at last chest X-ray | 20 % (24/120) | Chi-square, p = 0.45 |
| Residual pneumothorax at last chest X-ray | 12 % (14/120) | Chi-square, p = 0.55 |
| Necessity for second drainage insertion | 10 % (12/120) | Chi-square, p = 0.40 |
| Air leakage > 5 days | 8 % (10/120) | Chi-square, p = 0.62 |
| In-hospital stay (days) | Mean: 6.5, SD: 2.3 | ANOVA comparing patients with vs. without complications (residual hemothorax, air leakage >5 days, second drainage), p = 0.02 |
| 30-day mortality | 5 % (6/120) | Kaplan–Meier, p = 0.76 |
| 90-day readmission for effusion | 7 % (8/120) | Logistic regression, p > 0.05 |
| 90-day readmission for pneumothorax (PNX) | 5 % (6/120) | Chi-square, p = 0.58 |
p-value for in-hospital stay obtained using ANOVA, comparing patients with and without post-procedure complications (residual hemothorax, prolonged air leakage, second drainage insertion).
3.5. Complication rates and safety outcomes of the improvised CTD system
The improvised CTD system demonstrated an acceptable safety profile with manageable complication rates. The most frequent complication was tube repositioning in 25 % (N = 30), which showed a statistically significant association with pneumothorax and hemothorax (p < 0.05). Subcutaneous emphysema occurred in 20 % (N = 24) and was significantly associated with pneumothorax and hemopneumothorax (p < 0.05). Atelectasis was noted in 15 % (N = 18), with a trend toward significance in older age groups (p = 0.08). Empyema developed in 12 % (N = 14), significantly associated with male gender and age group 41–60 years (p < 0.05). Tube obstruction was observed in 10 % (N = 12), showing significant links to smoking status and pneumothorax cases (p = 0.05). Less frequent complications included accidental dislodgment 8 % (N = 10), tube kinking 5 % (N = 6), wrong placement (4 %, N = 5), and tube site sepsis 3 % (N = 4); although these were not statistically significant, they highlight technical challenges associated with improvised systems. These findings, illustrated in descending order in (Fig. 5).
Fig. 5.
Complications Associated with the Improvised CTD System.
3.6. Analysis of complications and risk factors in improvised CTD usage
The study identified several frequent complications with significant associations to patient characteristics and risk factors. Tube repositioning 25 % (N = 30) showed significant associations across different age groups (p = 0.03) and was more common in civilian patients (p = 0.04). Subcutaneous emphysema 20 % (N = 24) was significantly associated with female gender (p = 0.02) and current smoking status (p = 0.03). Empyema 12 % (N = 14) demonstrated significant associations with male gender (p = 0.01) and the 41–60 year age group (p = 0.03). Atelectasis 15 % (N = 18) was more frequently observed in patients over 60 years of age (p = 0.05). Tube obstruction 10 % (N = 12) showed significant relationships with current smoking (p = 0.02) and older age (p = 0.04). Additionally, accidental dislodgment (8 %, N = 10) was more common among current smokers (p = 0.04) and females (p = 0.05). Other complications such as tube kinking, tube site sepsis, and wrong placement did not reach statistical significance but remain important considerations for procedural refinement and safety monitoring. These findings are summarized in (Fig. 6).
Fig. 6.
Complication Rates and Associated Factors in Patients Undergoing Improvised CTD.
3.7. Analysis of complications associated with improvised CTD and their statistical significance across different thoracic injury types
Detailed analysis demonstrated that subcutaneous emphysema was significantly associated with pneumothorax (p = 0.02) and hemopneumothorax (p = 0.04). Tube obstruction showed strong associations with hemopneumothorax (p = 0.01) and borderline significance with pneumothorax (p = 0.05). Tube repositioning was significantly associated with pneumothorax (p = 0.03), hemothorax (p = 0.05), and flail chest (p = 0.02). Empyema also displayed significant associations with pneumothorax (p = 0.01), hemothorax (p = 0.04), and hemopneumothorax (p = 0.02). In contrast, other complications, including tube site sepsis, accidental dislodgement, tube kinking, and wrong placement, were observed less frequently and did not show statistically significant associations with injury type (all p > 0.05). These findings, summarized in (Table 4).
Table 4.
Complications and Their Statistical Significance Across Different Types of Thoracic Injuries.
| Complication |
Pneumothorax |
Hemothorax |
Hemopneumothorax |
Chylothorax |
Esophageal Injury |
Flail Chest |
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|---|---|---|---|---|---|---|---|---|---|---|---|---|
| N | p-value | N | p-value | N | p-value | N | p-value | N | p-value | N | p-value | |
| Atelectasis | 12 | 0.25 | 10 | 0.31 | 8 | 0.12 | 0 | 0.53 | 0 | 0.62 | 2 | 0.08 |
| Subcutaneous Emphysema | 15 | 0.02 | 12 | 0.09 | 9 | 0.04 | 0 | 0.67 | 0 | 0.55 | 3 | 0.14 |
| Tube Kinking | 3 | 0.48 | 2 | 0.35 | 1 | 0.21 | 0 | 0.80 | 0 | 0.90 | 0 | 0.33 |
| Tube Obstruction | 5 | 0.05 | 4 | 0.08 | 3 | 0.01 | 0 | 0.75 | 0 | 0.65 | 0 | 0.22 |
| Tube Repositioning | 10 | 0.03 | 8 | 0.05 | 7 | 0.07 | 0 | 0.85 | 0 | 0.78 | 2 | 0.02 |
| Tube Site Sepsis | 2 | 0.20 | 1 | 0.11 | 1 | 0.14 | 0 | 0.91 | 0 | 0.83 | 0 | 0.45 |
| Accidental Dislodgment | 5 | 0.33 | 3 | 0.27 | 2 | 0.18 | 0 | 0.60 | 0 | 0.70 | 0 | 0.55 |
| Wrong Placement | 2 | 0.07 | 2 | 0.12 | 1 | 0.09 | 0 | 0.95 | 0 | 0.88 | 0 | 0.11 |
| Empyema | 7 | 0.01 | 5 | 0.04 | 2 | 0.02 | 0 | 0.77 | 0 | 0.81 | 0 | 0.05 |
3.8. Resource utilization and cost efficiency
The improvised CTD system demonstrates significant cost savings, reducing expenses by approximately 87 %–88 % compared to conventional systems. Additionally, assembly from locally available materials was rapid (10–15 min) and did not depend on external supply chains, which are often disrupted in conflict settings (Table 5).
Table 5.
Presents a comparative summary of resource utilization and cost efficiency.
| Parameter | Conventional CTD System (Estimated) | Improvised CTD System (This Study) |
|---|---|---|
| Chest tube cost per unit | USD 1.90–2.80 | USD 1.50 (NG tube) |
| Underwater seal drainage bottle | USD 11.50 | USD 0.20–0.30 |
| Total setup cost per patient | USD 13.40–14.30 | USD 1.70–1.80 |
| Procurement time | Dependent on international supply chains | Immediately available from local materials |
| Suction application ability | Available in standard systems | Not available |
| Time to readiness for insertion | Pre-packaged sterile kits (ready when available) | Requires simple assembly (10–15 min) |
| Environmental sustainability | Single use, imported materials | Locally recycled and sterilized materials |
| Cost savings percentage | — | Approximately 87 %–88 % reduction compared to conventional systems |
3.9. Patient satisfaction analysis and its association with trauma type and complications
Among the 114 surviving patients assessed, overall satisfaction was high, with 60 % reporting being very satisfied and 25 % satisfied. Patients with uncomplicated thoracic injuries reported the highest satisfaction rates (p < 0.001). In contrast, those who experienced complications such as tube repositioning, empyema, and subcutaneous emphysema showed significantly lower satisfaction levels (p = 0.01, p = 0.01, and p = 0.04 respectively). Satisfaction scores were also slightly lower among patients with more severe trauma types, including hemopneumothorax and mixed injuries. These findings highlight the impact of both injury severity and complication occurrence on patient-perceived outcomes (Table 6).
Table 6.
Patient Satisfaction (N = 114 survivors) Cross-Tabulated with Chest Trauma Type and Complications.
| Parameter | Very Satisfied | Satisfied | Neutral | Dissatisfied | Very Dissatisfied | p-value |
|---|---|---|---|---|---|---|
| Type of Chest Trauma | ||||||
| Pneumothorax (n = 46*) | 30 (65.2 %) | 10 (21.7 %) | 4 (8.7 %) | 2 (4.3 %) | 0 (0 %) | 0.02 |
| Hemothorax (n = 37*) | 18 (48.6 %) | 12 (32.4 %) | 4 (10.8 %) | 3 (8.1 %) | 0 (0 %) | 0.03 |
| Hemopneumothorax (n = 23*) | 11 (47.8 %) | 7 (30.4 %) | 3 (13 %) | 2 (8.7 %) | 0 (0 %) | 0.04 |
| Other injuries (n = 8*) | 3 (37.5 %) | 2 (25 %) | 2 (25 %) | 1 (12.5 %) | 0 (0 %) | 0.06 |
| Complications Developed | ||||||
| No complications (n = 44) | 39 (88.6 %) | 4 (9.1 %) | 1 (2.3 %) | 0 (0 %) | 0 (0 %) | <0.001 |
| Tube repositioning (n = 28*) | 10 (35.7 %) | 10 (35.7 %) | 4 (14.3 %) | 3 (10.7 %) | 1 (3.6 %) | 0.01 |
| Empyema (n = 12*) | 3 (25 %) | 4 (33.3 %) | 3 (25 %) | 2 (16.7 %) | 0 (0 %) | 0.01 |
| Subcutaneous emphysema (n = 22*) | 9 (40.9 %) | 8 (36.4 %) | 3 (13.6 %) | 2 (9.1 %) | 0 (0 %) | 0.04 |
| Tube obstruction (n = 11*) | 4 (36.4 %) | 4 (36.4 %) | 2 (18.2 %) | 1 (9 %) | 0 (0 %) | 0.05 |
| Accidental dislodgment (n = 10) | 4 (40 %) | 3 (30 %) | 2 (20 %) | 1 (10 %) | 0 (0 %) | 0.05 |
4. Discussion
This study contributes significantly to the management of thoracic injuries in resource-limited and conflict-affected settings by evaluating the safety and efficacy of an improvised CTD system. Using NG tubes and locally sterilized water bottles, the system achieved 90 % lung re-expansion within 72 h, demonstrating outcomes comparable to conventional CTD systems (5,6). The necessity of adaptable healthcare solutions has been underscored by the COVID-19 pandemic and ongoing geopolitical crises, particularly in Syria, Yemen, and Sudan, where healthcare infrastructure remains fragile ([12], [13], [14]).
Improvised CTD techniques have been previously described in low-resource settings, but most studies focused on non-conflict environments (15,16). In contrast, our study evaluates an improvised system within an active conflict zone, where logistical and safety challenges are more pronounced (17). Additionally, while prior research primarily addressed thoracic injuries due to tuberculosis or malignancies (6,18), our study focuses on trauma-induced injuries, commonly caused by gunshot wounds and explosive devices. This distinction is crucial, as thoracic trauma in conflict settings requires immediate intervention, often in the absence of conventional equipment.
The complication rates observed in our study are largely consistent with standard CTD methods. For instance, the Empyema 12 % (N = 14) slightly exceeds the 1–2.4 % range reported in studies utilizing large-bore conventional chest tubes but remains within expectations for low-resource settings (6,19). The prolonged hospital stay observed in our study is likely attributable to the smaller caliber of the NG tube (0.3 cm internal diameter vs. 1 cm in conventional chest tubes), reducing drainage velocity and prolonging the duration of treatment. A similar trend was reported in Nigeria, where improvised CTD required longer placement durations (6). Conversely, an Iranian study found that conventional CTD were removed within 5–7 days, which is longer than the average duration in our study (20).
Foley catheters and Penrose drains have been used as improvised drainage methods in low-resource settings. Ben-Nun and Best (2008) reported 3500 successful cases using Foley catheters for pleural effusions, but their lack of an underwater seal limits their use in trauma cases. Penrose drains, reliant on passive drainage, pose a higher risk of obstruction and contamination. Compared to these, the nasogastric tube system in this study offers better pleural pressure regulation and greater adaptability for thoracic trauma, making it a more effective alternative in conflict settings where conventional CTD systems are unavailable (21).
Age-related complications were notable in this study, with atelectasis more frequent in older patients (>60 years), aligning with previous research linking age to higher intraoperative lung injury risks (19,22). However, some studies report no significant correlation (20). Similarly, subcutaneous emphysema was more common in older patients and those with hemothorax or hemopneumothorax, consistent with prior findings associating these factors with larger pneumothoraxes (23).
We observed a correlation between empyema and conditions such as pneumothorax, hemothorax, hemopneumothorax, and flail chest, which aligns with studies indicating that residual hemothorax increases empyema risk (24,25). In penetrating trauma, empyema typically results from direct pleural space contamination, while in blunt trauma, its incidence is linked to injury severity (25). Additionally, rib fractures have been identified as independent risk factors for empyema (26,27), emphasizing the need for vigilant monitoring in such cases.
Management of esophageal injury traditionally involves total parenteral nutrition (TPN) to prevent food leakage into the chest cavity. However, in low-resource settings where TPN is unavailable, enteral feeding through a gastrostomy tube serves as a practical alternative. In our case, despite persistent drainage for six weeks, spontaneous resolution occurred without surgical intervention (28). However, the prolonged duration necessitated tube replacement several times due to clogging and infection risk. Similarly, chylothorax management often relies on dietary modifications, including a medium-chain triglyceride (MCT) diet or TPN. In settings lacking these resources, surgical intervention may be required. In our patient, thoracotomy with thoracic duct ligation was successfully performed, highlighting the adaptability of management strategies in resource-limited environments (29).
In this study, six patients (5 %) died within 30 days. The causes of death were primarily related to severe thoracic injuries and systemic limitations. Three deaths occurred in patients who required thoracotomy for major bronchial injuries and massive hemothorax but developed postoperative respiratory failure. Two deaths were associated with bilateral flail chest injuries, where escalation of care was hindered by the lack of ICU availability. The sixth death was linked to persistent pneumothorax complicated by massive subcutaneous emphysema and sepsis. These outcomes highlight not only the severity of the initial trauma but also the critical impact of resource constraints in conflict settings.
The high satisfaction rates observed reflect the practicality of improvised chest tube drainage systems in resource-limited settings, as reported by Baird and Gibbons (2004) (16). Complications like tube repositioning and empyema reduced satisfaction, emphasizing the importance of proper technique and monitoring (30). Additionally, patients with complex injuries, such as hemopneumothorax, reported lower satisfaction, consistent with findings by Masood et al. (2023) (31). Overall, the system remains a well-tolerated and viable option in low-resource and conflict settings.
The findings of this study hold broader global significance, particularly in developing countries and disaster-stricken areas, where chest drainage resources are often scarce. During natural disasters, pandemics, and conflicts, the availability of conventional CTD may be severely compromised. The COVID-19 pandemic demonstrated how global supply chain vulnerabilities can lead to shortages of essential medical devices (13,14,32).
The improvised CTD system offers a scalable, cost-effective alternative, requiring only locally available materials. Its simple assembly makes it feasible for first responders and healthcare providers with limited resources. Given its success in managing thoracic trauma in conflict settings, this model could be integrated into emergency preparedness protocols by humanitarian organizations, including the WHO and Médecins Sans Frontières (MSF) ([33], [34], [35]).
This is the first study to rigorously evaluate the safety and efficacy of an improvised CTD system in a conflict zone, addressing a critical gap in thoracic trauma management in resource-constrained environments. Unlike prior research focusing on non-traumatic or non-conflict-related chest conditions, our findings highlight the feasibility of delivering life-saving interventions in extreme conditions using locally available materials.
The improvised system is particularly innovative, allowing for accurate monitoring while reducing complication risks. By demonstrating clinical outcomes comparable to conventional systems, this study provides a foundation for integrating cost-effective, improvised solutions into emergency care protocols, potentially shaping global healthcare policies for low-resource and conflict settings.
4.2. Limitations and future directions
This study has several limitations. Conducting a randomized controlled trial (RCT) was not feasible due to ethical and logistical constraints in a conflict setting, limiting the strength of findings. As a single-center study, generalizability is restricted, particularly to settings without trained personnel, as experienced registrars performed procedures.
The improvised CTD drainage system, while cost-effective, has drawbacks, including limited fluid capacity requiring frequent emptying, increased risk of contamination, inability to apply suction, higher occlusion risk, and potential tube dislodgement leading to pneumothorax recurrence. Additionally, patient mobility is restricted as they must remain supine to prevent water entry into the lungs.
Selection bias may be present as patients with severe comorbidities and major injuries were excluded, limiting applicability to high-risk cases. The short follow-up period (3 months) prevents assessment of long-term complications such as recurrent pneumothorax, chronic empyema, or pulmonary function changes.
Future research should include sex- and gender-based analysis (SGBA) to explore potential differences in outcomes. Multicenter studies and longer follow-up periods with pulmonary function testing are needed to enhance generalizability and assess long-term safety. Additionally, RCTs comparing the improvised CTD system with conventional CTD system are essential to establish stronger evidence.
5. Conclusion
This study highlights the improvised CTD system as a practical, effective, and economical solution for managing thoracic emergencies in conflict zones. Its adaptability and resourcefulness address critical gaps in emergency care, offering a lifeline to patients who would otherwise lack access to essential interventions.
The findings underscore the system's potential as a cost-effective and accessible alternative in settings where conventional CTD systems are unavailable due to logistical or infrastructural challenges. This research contributes to the broader field of surgical innovation and emergency preparedness, providing valuable insights for improving thoracic care in low-resource environments. Its implementation could serve as a model for similar conflict-affected or resource-limited settings worldwide.
CRediT authorship contribution statement
Alsadig Suliman: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Software, Resources, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization. Rawan Mohamedosman: Writing – original draft, Visualization, Investigation, Data curation. Bushra Suliman: Formal analysis, Software. Hassan Musa: Writing – review & editing, Validation, Project administration, Formal analysis. Siddig Ali: Visualization, Software, Methodology, Formal analysis, Conceptualization. Mohammad Ahmed: Data curation.
Declaration of competing interest
The authors declare no conflicts of interest related to this study. No financial, personal, or professional relationships with other individuals or organizations influenced the design, execution, or reporting of this research. All authors affirm their impartiality and independence in conducting this study.
Acknowledgments
Funding
None.
Statement of interest
None to declare.
Acknowledgment
We sincerely thank the Ministry of Health and the General Director of Wad Madani Teaching Hospital for their exceptional support and leadership, especially in navigating the challenges of delivering surgical care in a conflict-affected region. We are profoundly grateful to the hospital staff, including the dedicated doctors volunteering their time and expertise under extraordinary circumstances, and to the team for their unwavering collaboration. Special thanks to the thoracic surgery consultants and radiologists for their invaluable expertise, and to the patients for their participation in this study.
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