Comparison of outcomes between observation and tube thoracostomy for small traumatic pneumothoraces

Banks, Kian C.; Mooney, Colin M; Mazzolini, Kirea; Browder, Timothy; Victorino, Gregory P.

doi:10.1016/j.ajem.2023.01.017

Cited by 5 publications

(4 citation statements)

References 12 publications

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“…Recent work has demonstrated an association between pneumothorax size on CXR and failed observation; however, this study was in a small number of patients, and excluded critically ill patients, those with hemothorax, and those with bilateral pneumothorax. 26 Our findings are a more robust and generalizable demonstration of this effect due to a larger sample size, broader inclusion of patients, and fewer excluded individuals.…”

Section: Discussionsupporting

confidence: 51%

Using Chest X-Ray to Predict Tube Thoracostomy in Traumatic Pneumothorax: A Single-Institution Retrospective Review

Srinivas,

Henderson,

Bergus

et al. 2024

J Trauma Acute Care Surg

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Introduction Traumatic pneumothorax (PTX) is a common occurrence in thoracic trauma patients, with a majority requiring tube thoracostomy (TT) for management. Recently, the “35-mm” rule has advocated for observation of patients with PTX less than 35 mm on chest computed tomography (CT) scan. This rule has not been examined in chest x-ray (CXR). We hypothesize that a similar size cutoff can be determined in CXR predictive of need for tube thoracostomy. Methods We performed a single-institution retrospective review of patients with traumatic PTX from 2018 – 2022, excluding those who underwent TT prior to CXR. Primary outcomes were size of pneumothorax on CXR and need for TT; secondary outcome was failed observation, defined as TT more than four hours after presentation. To determine the size cutoff on CXR to predict TT need, area under the receiver operating curve (AUROC) analyses were performed and Youden’s index calculated (significance at p < 0.05). Predictors of failure were calculated using logistic regression. Results There were 359 pneumothoraces in 322 patients (94.4% blunt trauma, median injury severity score 14). Of these, 82 (22.8%) had a TT placed within the first four hours. Fifty-five of observed patients (21.2%) failed, and these patients had a larger PTX on CXR (8.6 mm [5.0 – 18.0 mm] versus 0.0 mm [0.0 – 2.3 mm] (p < 0.001)). CXR PTX size correlated moderately with CT size (r = 0.31, p < 0.001) and was highly predictive of need for TT insertion (AUC 0.75, p < 0.0001), with an optimal size cutoff predicting TT need of 38 mm. Conclusion CXR imaging size was predictive of need for TT, with an optimal size cutoff on CXR of 38 mm, approaching the “35-mm rule.” In addition to size, failed observation was predicted by presenting lactic acidosis and need for supplemental oxygen. This demonstrates this cutoff should be considered for prospective study in CXR. Level of Evidence: III; Therapeutic/Care Management

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Section: Discussionsupporting

confidence: 51%

Using Chest X-Ray to Predict Tube Thoracostomy in Traumatic Pneumothorax: A Single-Institution Retrospective Review

Srinivas,

Henderson,

Bergus

et al. 2024

J Trauma Acute Care Surg

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“…A meticulous analysis was conducted of 22 relevant publications evaluating conservative treatment for patients with a traumatic PTX. We selected 12 articles [13][14][15][16][17][18][19][20][21][22][23][24] where needle aspiration was also discussed as a conservative treatment option. We summarize all data extracted from these 12 studies in Table 1, which includes the first author, the year of publication, the study reference, patient groups, the study type, and outcomes and key results.…”

Section: Resultsmentioning

confidence: 99%

“…Table 1. Data on twelve selected papers [13][14][15][16][17][18][19][20][21][22][23][24] on conservative management of PTX, including the first author, the year of publication, the study reference, patient groups, the type of study, and outcomes (LOS, length of stay; RCT, randomized clinical trial; RD, respiratory distress).…”

Section: Resultsmentioning

confidence: 99%

“…The advent of CT imaging has increased the identification of occult PTXs, defined as a PTX detected on CT but not suspected on clinical evaluation or chest X-rays. This increased sensitivity has led surgeons to question whether tube decompression is really necessary for small PTXs, and some authors have suggested that this CT finding of an occult PTX does not have an impact on patient outcome and, therefore, no treatment can be necessary other than a period of observation [7,14,15].…”

Section: Discussionmentioning

confidence: 99%

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Successful Needle Aspiration of a Traumatic Pneumothorax: A Case Report and Literature Review

Bettoni,

Gheda,

Altomare

et al. 2024

Medicina

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Traumatic pneumothorax (PTX) occurs in up to 50% of patients with severe polytrauma and chest injuries. Patients with a traumatic PTX with clinical signs of tension physiology and hemodynamic instability are typically treated with an urgent decompressive thoracostomy, tube thoracostomy, or needle decompression. There is recent evidence that non-breathless patients with a hemodynamically stable traumatic PTX can be managed conservatively through observation or a percutaneous pigtail catheter. We present here a 52-year-old woman who presented to the emergency department with a 55 mm traumatic PTX. Following aspiration of 1500 mL of air, a clinical improvement was immediately observed, allowing the patient to be discharged shortly thereafter. In hemodynamically stable patients with a post-traumatic PTX, without specific risk factors or oxygen desaturation, observation or simple needle aspiration can be a reasonable approach. Although the recent medical literature supports conservative management of small traumatic PTXs, guidelines are lacking for hemodynamically stable patients with a significantly large PTX. This case report documents our successful experience with needle aspiration in such a setting of large traumatic PTX. We aimed in this article to review the available literature on needle aspiration and conservative treatment of traumatic pneumothorax. A total of 12 studies were selected out of 190 articles on traumatic PTX where conservative treatment and chest tube decompression were compared. Our case report offers a novel contribution by illustrating the successful resolution of a sizable pneumothorax through needle aspiration, suggesting that even a large PTX in a hemodynamically stable patient, without other risk conditions, can be successfully treated conservatively with simple needle aspiration in order to avoid tube thoracostomy complications.

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Can Concurrent Traumatic Hemopneumothorax be Safely Observed?

Al Tannir,

Tentis,

Maring

et al. 2024

Journal of Surgical Research

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Comparison of outcomes between observation and tube thoracostomy for small traumatic pneumothoraces

Cited by 5 publications

References 12 publications

Using Chest X-Ray to Predict Tube Thoracostomy in Traumatic Pneumothorax: A Single-Institution Retrospective Review

Using Chest X-Ray to Predict Tube Thoracostomy in Traumatic Pneumothorax: A Single-Institution Retrospective Review

Successful Needle Aspiration of a Traumatic Pneumothorax: A Case Report and Literature Review

Can Concurrent Traumatic Hemopneumothorax be Safely Observed?

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