Factors Associated with Chest Tube Placement in Blunt Trauma Patients with an Occult Pneumothorax

Abstract

Background. An occult pneumothorax is identified by computed tomography but not visualized by a plain film chest X-ray. The optimal management remains unclear. Methods. A retrospective review of an urban level I trauma center’s trauma registry was conducted to identify patients with occult pneumothorax over a 2-year period. Factors predictive of chest tube placement were identified using univariate and multivariate logistic regression analysis. Results. A total of 131 patients were identified, of whom 100 were managed expectantly with an initial period of observation. Ultimately, 42 (32.0%) patients received chest tubes and 89 did not. The patients who received chest tubes had larger pneumothoraces at initial assessment, a higher incidence of rib fractures, and an increased average number of rib fractures, of which significantly more were displaced. Conclusions. Displaced rib fractures and moderate-sized pneumothoraces are significant factors associated with chest tube placement in a victim of blunt trauma with occult pneumothorax. The optimal timing for the first follow-up chest X-ray remains unclear.

Chest Tube Placement in Mechanically Ventilated Trauma Patients: Differences between Computed Tomography-Based Indication and Clinical Decision

“…The size of the pneumothorax did not appear to be significant in determining the need for chest tube placement [ 27 ]. This is in contrast to another study that identified displaced rib fractures and moderate-sized pneumothorax as significant factors associated with chest tube placement in patients with blunt chest trauma and occult pneumothorax [ 28 ]. In another study, the conservative treatment of occult hemothorax failed in about 23% of patients, in which hemothorax volumes of more than 300 mL and the need for mechanical ventilation had the highest predictive value for chest tube placement [ 29 ].…”

“…Close cardiopulmonary monitoring is considered important, and appropriate preparations for emergent chest tube placement are essential in case the clinical condition deteriorates [ 31 ]. The optimal timing for plain chest radiography, CT follow-up, or bedside pleural ultrasound examination is not provided in the guidelines, but close intervals are recommended in clinically unstable patients [ 28 , 32 ].…”

Blunt chest wall trauma

“…Baseline pulmonary function tests including incentive spirometry and forced vital capacity (FVC) can help predict a higher risk of respiratory failure. Patients with an incentive spirometry volume less than 1,000 mL on admission and those with a predicted FVC of 55% or less demonstrate higher respiratory complication rates 2,17. According to the American Association for Respiratory Care, the proper use of incentive spirometry includes inspiration over 5 seconds, followed by a breath hold and natural unforced exhalation 4.…”

“…However, with increased use of CT technology, smaller pneumothoraxes may be identified and may not have clinical significance. An occult pneumothorax is identified on CT but not visible on radiograph 17. The current recommendation for an occult pneumothorax is monitoring vital signs with close interval follow-up radiographs.…”

“…The current recommendation for an occult pneumothorax is monitoring vital signs with close interval follow-up radiographs. Repeat chest radiographs can help clinicians monitor for expansion of an initial occult pneumothorax that may subsequently need more invasive treatment 17…”