The Buzdar Technique for Pulmonary Parenchymal Chest Tube Removal: Prospective Evaluation of a Novel Minimally Invasive Protocol

Chest tube thoracostomy remains a cornerstone in the management of pleural and thoracic pathologies, including pneumothorax, hemothorax, empyema, and pleural effusions. By lowering intrapleural pressure and promoting lung re-expansion, it ensures adequate tissue oxygenation and effective ventilation [1, 2]. Despite its widespread use, complication rates following tube thoracostomy remain high-ranging from 20% to 40%-and include insertional, positional, and infectious events. Pneumothorax and chest trauma are among the major causes of thoracic morbidity in Pakistan. In a Karachi-based study, 40% of 146 pneumothorax cases were attributed to traumatic and iatrogenic causes, with intercostal tube drainage utilized in 81% of patients. Similarly, another study reported that 35% of thoracic trauma patients experienced tube-related complications such as empyema and bronchopleural fistula. These findings underscore the urgent need for procedural standardization, improved operator training, and enhanced complication management strategies.

Tube thoracostomy is a frequently performed procedure in emergency and trauma care settings, taught in most surgical and medical training curricula and standardized within the Advanced Trauma Life Support (ATLS) program. Nevertheless, globally, insertion-related complications continue to present significant clinical challenges. International literature has emphasized the importance of standardized classification and reporting systems for chest tube-related complications, broadly categorizing them into insertional, positional, removal, infectious, and device-related events. The implementation of such standardized systems and adherence to best-practice protocols have been shown to reduce complication rates significantly-from 12.6% to as low as 4.4% in some trauma centers.

Among insertional complications, pulmonary parenchymal chest tube (PPcT) represents one of the most serious, occurring when the chest tube inadvertently traverses into the lung tissue. PPcT is particularly associated with patients who have pleural adhesions, poor pulmonary compliance, or consolidated lungs. Despite its potential to cause catastrophic outcomes such as bleeding or bronchopleural fistula, PPcT remains underreported and lacks standardized management guidelines. Reported interventions for removal are limited to invasive surgical approaches such as thoracotomy with thoracoplasty and video-assisted thoracic surgery (VATS) without lung resection. However, no literature currently describes minimally invasive, staged, or gradual removal techniques for such cases.

At the Department of Thoracic Surgery, Services Hospital, Lahore, Punjab, Pakistan, several cases of PPcT have been managed over the last decade. In response to this clinical challenge, our team developed a novel, minimally invasive three-stage removal strategy, termed the Buzdar Technique, initiated in 2006. This standardized protocol aims to achieve safe removal of intraparenchymal chest tubes without the need for thoracotomy or VATS while minimizing morbidity and preventing recurrence or pneumothorax. The method involves: (1) leaving the tube in situ for approximately two weeks to promote localized fibrosis; (2) gradual 2-cm retractions with optional 360° rotation under radiologic and clinical monitoring, followed by a 24-hour observation and chest radiograph; and (3) sequential weekly retractions until the last fenestration exits the pleural space, at which point safe removal is achieved.

This prospective cohort study, conducted from July 2025 to June 2026, aims to evaluate the effectiveness, safety, and clinical outcomes of the Buzdar Technique for managing pulmonary parenchymal chest tubes. By documenting its results systematically, this study seeks to provide evidence for a reproducible, less invasive alternative to surgical extraction, potentially establishing a new standard of care in managing PPcT.