Pediatric Emergency Tube Thoracostomy: Complications and Independent Risk Factors in a Five-Year Cohort

Abstract

Objectives

Tube thoracostomy is a frequently performed emergency procedure in pediatric patients; however, complication patterns and risk stratification in emergency settings remain incompletely defined. This study aimed to evaluate 30-day complication rates and identify independent predictors of adverse outcomes in pediatric patients undergoing tube thoracostomy in emergency settings.

Methods

This retrospective observational cohort study included 451 consecutive pediatric patients (0–18 years) who underwent tube thoracostomy between June 2020 and June 2025 at a tertiary referral center. Emergency settings included procedures performed in the Emergency Department (ED), Pediatric Intensive Care Unit (PICU), or urgent perioperative settings. The primary outcome was 30-day procedure-related complications. Variables with p<0.10 in univariate analysis were entered into a multivariate logistic regression model to determine independent predictors. Model calibration and discrimination were assessed using the Hosmer–Lemeshow test and the area under the receiver operating characteristic curve (AUC).

Results

The overall 30-day complication rate was 21.3% (96/451). More than half of the procedures were performed in the ED (53.9%). Complication rates were highest in children younger than 6 years (38.2%, p=0.001) and in those with traumatic presentations (36.0% vs. 19.5%, p=0.04). General anesthesia was associated with higher complication rates compared with local anesthesia with or without sedation (34.5% vs. 13.4%, p<0.001). Multivariate analysis identified age <6 years (adjusted OR: 2.42, 95% CI: 1.38–4.24), traumatic etiology (adjusted OR: 1.86, 95% CI: 1.02–3.39), and general anesthesia (adjusted OR: 2.18, 95% CI: 1.34–3.54) as independent predictors. Procedure location was not independently associated with complications. Model discrimination was acceptable (AUC: 0.71).

Conclusion

In pediatric emergency tube thoracostomy, younger age, traumatic presentation, and the use of general anesthesia are independently associated with 30-day complications. Comparable complication rates across the ED and other emergency settings support the safety of emergency department–based tube thoracostomy when performed by trained providers. These findings may guide risk stratification and clinical decision-making in pediatric emergency medicine.

Tube thoracostomy remains one of the most commonly performed emergency procedures in pediatric patients, serving as a critical intervention for conditions ranging from traumatic pneumothorax to parapneumonic effusions.^[1,2] Despite its frequent use and well-established role in emergency medicine, the procedure carries significant potential for morbidity, particularly in the pediatric population, in whom anatomical considerations and physiological differences necessitate specialized technical expertise.^[3,4] Contemporary literature indicates that complication rates following pediatric tube thoracostomy range from 15% to 25%, encompassing a spectrum from minor technical issues to life-threatening hemorrhage or organ injury.^[5,6]

The pediatric emergency department (ED) represents a unique clinical environment in which tube thoracostomy is frequently performed under time-sensitive conditions. Recent multicenter studies have highlighted substantial practice variation in pediatric pneumothorax management, with ongoing debate regarding optimal intervention strategies, including observation versus immediate drainage and the comparative effectiveness of different catheter types.^[7,8] Younger children, particularly those under 6 years of age, present distinctive challenges due to their compliant chest wall, smaller anatomical dimensions, and higher metabolic demands, factors that may influence both procedural difficulty and complication risk.^[9,10]

Traumatic thoracic injuries account for approximately 10–15% of pediatric trauma presentations requiring chest tube placement, with pneumothorax and hemothorax being the predominant indications.^[11,12] Meanwhile, nontraumatic etiologies—including spontaneous pneumothorax, parapneumonic effusions, and empyema—comprise the majority of pediatric tube thoracostomy cases. Parapneumonic effusions complicate approximately 0.6% of bacterial pneumonia cases in children, although regional variation exists depending on pneumococcal vaccination coverage and antimicrobial resistance patterns.^[13,14] The management of parapneumonic collections has evolved considerably in recent years, with increasing evidence supporting fibrinolytic therapy and video-assisted thoracoscopic surgery (VATS) as alternatives to traditional large-bore chest tube drainage.^[15,16]

Despite procedural familiarity among emergency physicians and pediatric surgeons, comprehensive pediatric-specific outcome data remain limited. Most management guidelines extrapolate from adult evidence, and practice patterns vary significantly among institutions.^[17,18] Critical questions persist regarding optimal patient selection for tube thoracostomy, risk stratification for complications, the role of general anesthesia versus local anesthesia with procedural sedation, and postprocedural management strategies.^[19,20] Furthermore, the impact of procedure location—whether performed in the ED, pediatric intensive care unit (PICU), or operating room—on complication rates and clinical outcomes has not been thoroughly characterized in large pediatric cohorts.

This retrospective cohort study was undertaken to address these knowledge gaps by analyzing 451 consecutive pediatric tube thoracostomy cases performed over a 5-year period at a tertiary referral center. We sought to characterize complication patterns, identify independent risk factors for adverse outcomes, and evaluate procedural safety across different emergency care settings. Particular emphasis was placed on emergency medicine perspectives, given that more than half of the procedures were performed in the ED setting. By examining a large, contemporary cohort with complete 30-day follow-up data, this study aimed to inform evidence-based practice guidelines and improve risk stratification for pediatric patients requiring emergency chest tube placement.

Methods

Study Design and Ethical Approval

This retrospective observational cohort study was conducted at a tertiary referral center with an active pediatric emergency department (ED) and pediatric intensive care unit (PICU). The study was approved by the Başakşehir Çam and Sakura City Hospital Ethics Committee (Approval No: KAEK/14.01.2026.15; dated January 20, 2026). Due to the retrospective design and use of anonymized data, informed consent was waived by the ethics committee. The study was conducted in accordance with the Declaration of Helsinki.

Study Population and Setting

All pediatric patients aged 0–18 years who underwent tube thoracostomy in emergency settings between June 1, 2020, and June 30, 2025, were screened for inclusion. Emergency settings were defined as procedures performed in the Emergency Department (ED), Pediatric Intensive Care Unit (PICU), or urgent perioperative settings in response to acute clinical deterioration. Although the study included patients across the full pediatric age spectrum, the cohort primarily reflected emergency department and acute care presentations. Neonatal patients requiring specialized neonatal intensive care management or bedside procedures under neonatal-specific conditions were not specifically represented as a distinct subgroup.

Inclusion Criteria

• Age 0–18 years

• Tube thoracostomy performed in emergency settings (ED, PICU, or urgent perioperative setting)

• Complete 30-day follow-up data available

Exclusion Criteria

• Elective prophylactic chest tube placement

• Incomplete medical records regarding 30-day complication status

• Procedures performed outside the study center

A total of 451 consecutive pediatric patients met the inclusion criteria and were included in the final analysis.

Clinical Variables and Definitions

Demographic and Presentation Characteristics

• Age (continuous and categorized as <6 years, 6–12 years, and 12–18 years). Due to the limited number of neonatal patients and the emergency-focused nature of the cohort, a separate neonatal subgroup analysis was not performed.

• Sex (male/female)

• Emergency presentation: categorized as spontaneous (nontraumatic acute respiratory distress, spontaneous pneumothorax, or infectious processes) or traumatic (blunt or penetrating chest trauma requiring emergency tube thoracostomy)

• Procedure location: Emergency Department (ED), Pediatric Intensive Care Unit (PICU), or urgent perioperative setting

Clinical Indications

Clinical indications were categorized as follows: (1) pneumothorax (spontaneous, traumatic, or iatrogenic/other); (2) pleural effusion/empyema; (3) hemothorax; or (4) urgent post-video-assisted thoracoscopic surgery (VATS) chest tube placement in the context of acute clinical deterioration.

Procedural Characteristics

Tube thoracostomy procedures were performed by pediatric surgeons, emergency physicians, or supervised senior residents according to institutional protocols. Anesthesia type was categorized as either general anesthesia or local anesthesia with or without procedural sedation. Tube diameter (French size), duration of drainage, and length of hospital stay were recorded from the medical records.

Outcome Measures

Primary Outcome

The primary outcome was 30-day procedure-related complications, defined as any of the following adverse events documented within 30 days of tube thoracostomy:

• Clinically significant hemorrhage requiring intervention (transfusion, reoperation, or prolonged chest tube drainage >7 days), defined as new-onset or procedure-related bleeding occurring after tube thoracostomy rather than preexisting hemorrhagic conditions such as traumatic hemothorax

• Persistent air leak (>7 days)

• Infection or pneumonia attributed to the procedure

• Subcutaneous emphysema

• Re-expansion pulmonary edema

Patients could experience more than one type of complication.

Secondary Outcomes

Secondary outcomes included ICU admission (considered a clinical outcome measure reflecting disease severity and complication burden rather than a preprocedural risk factor), tube duration (days), length of hospital stay (days), and 30-day mortality.

Statistical Analysis

Statistical analyses were performed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables were assessed for normality using the Kolmogorov–Smirnov test. Normally distributed variables were presented as mean±standard deviation; non-normally distributed variables were expressed as median (interquartile range). Categorical variables were presented as frequencies and percentages.

Group comparisons were performed using the chi-square test or Fisher’s exact test for categorical variables and Student’s t-test or the Mann–Whitney U test for continuous variables, as appropriate. A two-sided p-value<0.05 was considered statistically significant.

Results

Study Population and Emergency Department Context

Between June 1, 2020, and June 30, 2025, a total of 451 pediatric patients underwent tube thoracostomy in emergency settings. More than half of the procedures (53.9%, n=243) were performed in the emergency department (ED), with the remainder performed in the pediatric intensive care unit (PICU; 28.4%, n=128) and urgent perioperative settings (17.7%, n=80). The cohort comprised 345 males (76.5%) and 106 females (23.5%), with a mean age of 11.8±5.4 years (median: 14.0 years; range: 0.01–18 years). The overall 30-day complication rate was 21.3% (96/451) (Table 1).

Table 1.

Patient demographics and emergency presentation

Characteristic	Total (n=451)	Complication (n=96)	p
Gender			0.62
Male	345 (76.5%)	75 (21.7%)
Female	106 (23.5%)	21 (19.8%)
Age Group			0.001
<6 years	68 (15.1%)	26 (38.2%)
6–12 years	92 (20.4%)	18 (19.6%)
12–18 years	291 (64.5%)	52 (17.9%)
Emergency Presentation			0.04
Spontaneous	401 (88.9%)	78 (19.5%)
Traumatic	50 (11.1%)	18 (36.0%)
Procedure Location			0.09
Emergency Department	243 (53.9%)	46 (18.9%)
PICU	128 (28.4%)	32 (25.0%)
Urgent Perioperative	80 (17.7%)	18 (22.5%)

PICU: Pediatric Intensive Care Unit.

Complication rates differed significantly among age groups (χ²=13.86, df=2, p=0.001), with children younger than 6 years demonstrating the highest risk (38.2%) compared with those aged 6–12 years (19.6%) and 12–18 years (17.9%). Traumatic presentation was associated with significantly higher complication rates than spontaneous presentation (36.0% vs. 19.5%, p=0.04). Procedure location did not significantly affect complication rates (p=0.09), indicating comparable procedural safety across the ED, PICU, and urgent perioperative settings.

Clinical Indications and Procedural Characteristics

The most common indication for tube thoracostomy was pneumothorax (n=288, 63.9%), subdivided into spontaneous pneumothorax (n=218, 48.3%), traumatic pneumothorax (n=32, 7.1%), and iatrogenic/other pneumothorax (n=38, 8.4%). Pleural effusion/empyema accounted for 22.2% of cases (n=100), hemothorax for 5.1% (n=23), and urgent post-VATS chest tube placement for 8.9% (n=40). Clinical indication was significantly associated with complication rates (χ²=18.42, p=0.001), with post-VATS procedures demonstrating the highest complication rate (37.5%) (Table 2).

Table 2.

Clinical indications and procedural data

Variable	n (%)	Complication n (%)
Clinical Indication*
Pneumothorax (total)	288 (63.9%)	52 (18.1%)
- Spontaneous	218 (48.3%)	36 (16.5%)
- Traumatic	32 (7.1%)	9 (28.1%)
- Iatrogenic/Other	38 (8.4%)	7 (18.4%)
Pleural Effusion/Empyema	100 (22.2%)	24 (24.0%)
Hemothorax	23 (5.1%)	5 (21.7%)
Urgent Post-VATS	40 (8.9%)	15 (37.5%)
Anesthesia Type†
General Anesthesia	168 (37.3%)	58 (34.5%)
Local/Sedation	283 (62.7%)	38 (13.4%)
Tube diameter (Fr, mean±SD)	19.2 ± 6.8	—

^*χ²=18.42, p=0.001. †Chi-square test comparing general anesthesia vs. local/sedation; χ²=28.64, p<0.001. Fr: French; SD: Standard deviation; VATS: Video-assisted thoracoscopic surgery.

General anesthesia was used in 37.3% of cases and was significantly associated with increased complication rates (34.5% vs. 13.4%, p<0.001). The median tube duration was 6 days (IQR: 3–9), and the median hospital stay was 9 days (IQR: 6–15). Patients with complications had significantly longer tube durations (9 days vs. 5 days, p<0.001) and hospital stays (15 days vs. 8 days, p<0.001).

Complication Profile and Clinical Outcomes

Among the 96 patients (21.3%) who experienced complications within 30 days, hemorrhage was the most common complication (n=56, 58.3% of complications), followed by persistent air leak (n=38, 39.6%), infection (n=8, 8.3%), subcutaneous emphysema (n=4, 4.2%), and re-expansion pulmonary edema (n=2, 2.1%). Hemorrhage was defined as procedure-related bleeding occurring after tube thoracostomy and not as preexisting bleeding due to the underlying condition. Some patients experienced multiple complications. ICU admission was required in 152 patients (33.7%) overall and was significantly more common among patients with complications (50.0% vs. 29.0%, p<0.001), representing an important clinical outcome measure. Five patients (1.1%) died within 30 days; all deaths were attributed to underlying critical illness (polytrauma with multiorgan failure, n=3; severe pneumonia with septic shock, n=1; malignancy-related respiratory failure, n=1) rather than direct procedural complications (Table 3).

Table 3.

30-day complications and clinical outcomes

Outcome/Complication Type	n	% of Complications*
Hemorrhage/Bleeding†	56	58.3
Persistent Air Leak (>7 days)	38	39.6
Infection/Pneumonia	8	8.3
Subcutaneous Emphysema	4	4.2
Re-expansion Pulmonary Edema	2	2.1
Total Patients with Complications	96	—
ICU Admission (Outcome)‡	152	33.7%
30-Day Mortality§	5	1.1%

^*Percentages exceed 100% as some patients experienced multiple complications. †Hemorrhage defined as clinically significant bleeding requiring intervention (transfusion, re-operation, or prolonged drainage >7 days). ‡ICU admission significantly more common in patients with complications (48/96, 50.0%) vs. without complications (104/355, 29.0%), p<0.001. §All deaths attributed to underlying critical illness (polytrauma n=3, septic shock n=1, malignancy n=1), not direct procedural complications. ICU: Intensive care unit.

Risk Stratification for Emergency Complications

Multivariate logistic regression identified independent predictors of complications relevant to emergency risk stratification. Variables with p<0.10 in univariate analysis (age <6 years, traumatic etiology, urgent post-VATS indication, and general anesthesia) were included. The event-per-variable ratio was 24.0 (96 events/4 variables), exceeding the recommended minimum of 10. After adjustment, age <6 years (adjusted OR: 2.42, 95% CI: 1.38–4.24, p=0.002), traumatic etiology (adjusted OR: 1.86, 95% CI: 1.02–3.39, p=0.044), and general anesthesia (adjusted OR: 2.18, 95% CI: 1.34–3.54, p=0.002) remained significant independent predictors. However, the association between general anesthesia and complications should be interpreted with caution due to potential confounding by indication. Urgent post-VATS indication did not retain significance after adjustment (adjusted OR: 1.52, 95% CI: 0.78–2.96, p=0.22). Model calibration was acceptable (Hosmer–Lemeshow p=0.64), with fair discriminative ability (AUC: 0.71, 95% CI: 0.65–0.77; 5-fold cross-validation AUC: 0.68±0.09) (Table 4).

Table 4.

Emergency risk stratification: multivariate analysis

Risk Factor	Adjusted OR	95% CI
Age <6 years*	2.42	1.38–4.24
Traumatic etiology†	1.86	1.02–3.39
General anesthesia‡	2.18	1.34–3.54
Urgent post-VATS indication	1.52	0.78–2.96

^*p=0.002; †p=0.044; ‡p=0.002. Residual confounding by indication and case complexity may affect the general anesthesia estimate. Model based on 451 patients with 96 complications. Event-per-variable ratio=24.0. Variance inflation factor <2 for all variables. Model performance: AUC 0.71 (95% CI: 0.65–0.77); Hosmer–Lemeshow p=0.64; 5-fold cross-validation AUC: 0.68±0.09. AUC: Area under the curve, CI: Confidence interval; OR: Odds ratio; VATS: Video-assisted thoracoscopic surgery.

Discussion

This large single-center retrospective study of 451 pediatric patients undergoing tube thoracostomy in emergency settings provides important insights into contemporary complication patterns and risk stratification. Our overall 30-day complication rate of 21.3% aligns with recently published estimates ranging from 15% to 25% in pediatric populations, although direct comparison is complicated by variations in complication definitions and study methodologies.^[5,6,21] Three key findings emerged from our analysis: first, age under 6 years independently predicted complications even after adjustment for other clinical factors; second, traumatic presentation carried nearly twice the complication risk compared with spontaneous etiologies; and third, procedure location (ED, PICU, or urgent perioperative setting) did not significantly affect complication rates, suggesting comparable procedural safety across emergency care environments when procedures are performed by experienced providers.

The identification of age under 6 years as an independent risk factor for complications (adjusted OR: 2.42) represents an important finding with direct clinical implications for emergency medicine practice. This heightened risk likely reflects the unique anatomical and physiological characteristics of young children, including smaller intercostal spaces, thinner chest wall musculature, and greater mediastinal mobility.^[9,10] Recent pediatric thoracic trauma literature has similarly documented age-dependent differences in both injury patterns and procedural outcomes.^[12] Our findings suggest that younger children may benefit from enhanced preprocedural planning, consideration of image-guided placement when feasible, and heightened postprocedural surveillance for early complication detection. The 38.2% complication rate observed in children under 6 years underscores the need for subspecialized pediatric emergency care capabilities and suggests that referral to tertiary centers may be appropriate for this high-risk subgroup when clinical circumstances permit.

The significantly elevated complication rate in traumatic presentations (36.0% vs. 19.5%, p=0.04) is consistent with the complexity of managing patients with polytrauma, who often present with multiple concurrent injuries, hemodynamic instability, and coagulopathy.^[11,12] Recent pediatric trauma guidelines emphasize the importance of systematic primary and secondary surveys, with tube thoracostomy representing one component of comprehensive resuscitation rather than an isolated procedure.^[11] The independent association between traumatic etiology and complications (adjusted OR: 1.86) persisted after controlling for age and anesthesia type, suggesting that trauma-specific factors—such as associated pulmonary contusion, rib fractures, or vascular injury—contribute to adverse outcomes beyond patient demographics alone. These findings support current Advanced Trauma Life Support (ATLS) recommendations for meticulous technique and close monitoring in pediatric trauma patients undergoing chest tube placement.

General anesthesia was associated with an increased risk of complications in our analysis; however, this finding should be interpreted with caution. It is highly plausible that this association reflects confounding by indication, as patients with greater clinical severity, hemodynamic instability, or procedural complexity are more likely to require general anesthesia. Although multivariate adjustment was performed, residual confounding due to unmeasured severity-related factors cannot be excluded. Therefore, our results do not establish a causal relationship between general anesthesia and complications but rather indicate an association that may be mediated by the underlying patient condition. Prospective studies incorporating objective severity scoring systems are needed to better clarify this relationship.^[19,20,22]

The finding that procedure location did not significantly affect complication rates (ED: 18.9%, PICU: 25.0%, urgent perioperative setting: 22.5%, p=0.09) provides reassuring evidence for the safety and effectiveness of emergency department tube thoracostomy when performed by trained providers. This observation challenges potential institutional biases favoring operating room placement and supports current emergency medicine practice patterns.^[19,20] More than half of our procedures (53.9%) were successfully completed in the ED setting, demonstrating that emergency physicians can safely perform this procedure when appropriate protocols, equipment, and supervision are available. Recent consensus statements emphasize that procedural competency depends more on provider training and experience than on physical location, although institutional support systems, including rapid access to pediatric surgery consultation and postprocedural ICU care, remain essential.^[19]

Hemorrhage emerged as the most common complication (58.3% of all complications), followed by persistent air leak (39.6%). Importantly, hemorrhage in our study refers to procedure-related bleeding rather than preexisting hemorrhagic conditions, which may be present particularly in trauma patients. These findings align with contemporary complication profiles reported in recent systematic reviews, although the relative frequency of specific complications varies across studies depending on definitions and ascertainment methods.^[2,5,6] Our strict definition of hemorrhage requiring clinical intervention, such as transfusion, reoperation, or prolonged drainage with ongoing bleeding, ensures clinical relevance while potentially underestimating minor bleeding events. The relatively low infection rate (8.3% of complications) may reflect institutional protocols, including antibiotic prophylaxis, although current evidence regarding routine antibiotic use for tube thoracostomy remains inconclusive.^[23] Importantly, all five deaths in our cohort were attributed to underlying critical illness rather than direct procedural complications, suggesting that, when performed by experienced providers, tube thoracostomy carries minimal procedure-attributable mortality even in critically ill children.

Pneumothorax represented the most common indication (63.9% of cases), predominantly spontaneous in etiology. Recent pediatric literature has questioned traditional pneumothorax management paradigms, with emerging evidence supporting observation in stable patients with small to moderate pneumothoraces.^[7,8,24] A landmark multicenter Australian and New Zealand study demonstrated successful conservative management in appropriately selected pediatric spontaneous pneumothorax cases, with lower recurrence rates than previously estimated.^[8] Although our study focused on patients who underwent tube thoracostomy rather than those managed conservatively, these evolving practice patterns highlight the importance of careful patient selection and shared decision-making. Future prospective studies incorporating both intervention and observation arms would help refine indications for tube thoracostomy versus conservative management in pediatric pneumothorax.

Parapneumonic effusions and empyema accounted for 22.2% of our cohort, representing an important subset with distinct management considerations. Contemporary pediatric empyema management has evolved substantially, with increasing evidence supporting fibrinolytic therapy, typically with tissue plasminogen activator, as first-line treatment following chest tube placement, reserving VATS for refractory cases.^{[15,16,25,26]} A recent prospective randomized trial demonstrated equivalent outcomes between fibrinolysis and VATS, with fibrinolysis offering advantages in cost-effectiveness and avoidance of general anesthesia.^[15] Our study did not specifically analyze fibrinolytic use or empyema-specific outcomes, although the 24.0% complication rate in pleural effusion/empyema cases aligns with published series. Future iterations of this research should incorporate treatment-specific subgroup analyses to inform optimal management pathways for parapneumonic collections.

Urgent post-VATS chest tube placement represented 8.9% of cases and demonstrated the highest complication rate (37.5%), although this did not achieve statistical significance after multivariate adjustment (p=0.22). This elevated risk likely reflects the complexity of patients requiring VATS, many of whom have failed initial conservative management or have underlying pulmonary pathology. Recent pediatric thoracic surgery literature emphasizes careful patient selection for VATS and meticulous technique to minimize postoperative complications.^[27] The heterogeneity within this subgroup, spanning postoperative air leaks, residual effusions, and recurrent pneumothoraces, limits definitive conclusions, although the trend toward increased complications warrants attention in clinical practice and future research.

ICU admission occurred in 33.7% of patients overall and was significantly more common among those with complications (50.0% vs. 29.0%, p<0.001), representing an important clinical outcome measure reflecting disease severity and resource utilization. We deliberately conceptualized ICU admission as an outcome rather than a predictor to avoid reverse causality, although future prospective studies with more granular clinical data could explore whether specific ICU interventions, such as mechanical ventilation and vasopressor support, modify complication risk. The substantial ICU utilization in our cohort underscores the clinical significance of conditions requiring emergency tube thoracostomy and highlights the importance of coordinated multidisciplinary care involving emergency medicine, pediatric surgery, and intensive care specialists.^[19,28]

From a clinical perspective, our findings support several practical considerations. Younger children and patients with traumatic indications should be recognized as higher-risk groups requiring closer monitoring and potentially more experienced operators. When clinically feasible, the use of local anesthesia with procedural sedation may be preferred to minimize physiological stress, although this decision should be individualized based on the patient’s condition. In addition, the comparable complication rates across different emergency settings support the safety of emergency department–based tube thoracostomy when performed by adequately trained providers.

Strengths and Limitations

This study has several notable strengths, including its large sample size (n=451), contemporary 5-year study period, and complete 30-day follow-up data. The inclusion of emergency settings and procedures performed across the Emergency Department (ED), Pediatric Intensive Care Unit (PICU), and urgent perioperative settings provides a comprehensive and clinically relevant representation of real-world pediatric tube thoracostomy practice. Furthermore, the use of multivariate logistic regression with an adequate event-per-variable ratio (EPV=24.0), along with model validation (AUC: 0.71; cross-validation AUC: 0.68±0.09), strengthens the reliability of the identified independent risk factors. The explicit consideration of potential confounding by indication, particularly regarding general anesthesia, further enhances the methodological transparency of the study.

However, several limitations should be acknowledged. First, the retrospective observational design precludes definitive causal inference, and unmeasured confounding variables, such as disease severity, operator experience, and technical variations, may have influenced the observed associations. Second, as a single-center study, the generalizability of our findings may be limited in settings with different clinical practices or resource availability.

Additionally, the inclusion of a broad spectrum of clinical indications (e.g., pneumothorax, pleural effusion/empyema, and trauma) introduces inherent clinical heterogeneity. Although this reflects real-world emergency practice and enhances external validity, it may obscure indication-specific differences in complication risk. Although multivariate analysis was used to adjust for etiology, this approach cannot fully replace indication-specific subgroup analyses.

Furthermore, although very young patients were included, the study population does not specifically represent neonatal intensive care unit populations or bedside neonatal procedures. Given the distinct physiological and procedural considerations in neonates and the limited number of neonatal patients in our cohort, the absence of a dedicated neonatal subgroup analysis may restrict the applicability of our findings to this specific population.

In addition, data regarding the use of ultrasound guidance during tube thoracostomy were not consistently available and therefore could not be analyzed, which may represent an additional limitation given its potential impact on procedural safety and complication rates.

Future multicenter prospective studies with more homogeneous patient groups, standardized procedural protocols, and detailed technical data, including ultrasound guidance and age-specific subgroup analyses, particularly in neonatal populations, are warranted to better define risk profiles and optimize clinical decision-making in pediatric tube thoracostomy.

Clinical Implications

Our findings offer several practical implications for emergency medicine practice. First, children younger than 6 years requiring tube thoracostomy represent a high-risk population warranting enhanced vigilance, consideration of image-guided techniques, and potential referral to tertiary centers when feasible. Second, traumatic presentations require heightened awareness of potential complications, with systematic attention to associated injuries and coagulopathy. Third, the comparable safety of ED-based tube thoracostomy supports current emergency medicine practice when adequate training, institutional protocols, and support systems are in place. Fourth, although the association between general anesthesia and complications may reflect confounding, procedural sedation with local anesthesia merits consideration in appropriate patients. Finally, the substantial complication rate (21.3%) emphasizes the importance of careful patient selection, meticulous technique, and postprocedural monitoring regardless of procedure location.

Conclusion

In this large contemporary cohort of 451 pediatric patients undergoing emergency tube thoracostomy, age under 6 years and traumatic presentation emerged as independent predictors of 30-day complications. General anesthesia was also associated with increased complication rates, although this finding should be interpreted with caution due to potential confounding by indication. Procedure location did not significantly affect outcomes, supporting the safety of emergency department–based tube thoracostomy when performed by trained providers with appropriate institutional support. These findings provide practical guidance for risk stratification, patient counseling, and procedural decision-making in pediatric emergency care. Future prospective multicenter studies incorporating long-term outcomes, detailed procedural variables, and comparative effectiveness of management strategies are needed to further refine evidence-based guidelines for this common but high-risk emergency procedure.

Disclosures

Ethics Approval

Ethics committee approval for this study was obtained from the Başakşehir Çam and Sakura City Hospital (Approval no: KAEK/14.01.2026.15; date: January 20, 2026)

Informed consent

Due to the retrospective design and use of anonymized data, informed consent was waived by the ethics committee.

Conflict of Interest

The authors declare that there is no conflict of interest.

Financial Disclosure

This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Use of AI for Writing Assistance

The use of generative AI and AI-assisted technologies was restricted to English-language editing and enhancing the clarity and readability of the manuscript. These technologies were not used in the conception or design of the present study, in the collection, analysis, or interpretation of data, in the evaluation of the scientific literature, or in the formulation of the scientific content and conclusions. All scientific assessments and determinations were independently performed by the authors, who have read and approved the final manuscript and take full responsibility for its content.

Authorship Contributions

Concept – M.N.S.; Design – M.N.S., F.S.; Supervision – F.S.; Fundings – A.B., E.Z.Z.; Materials − A.B., E.Z.Z.; Data collection &/or processing – A.B., E.Z.Z.; Analysis and/or interpretation – A.B.; Literature search – M.N.S.; Writing – M.N.S.; Critical review – F.S.

Peer-review

Externally peer-reviewed.