Tube Thoracostomy for Occult Pneumothorax-a Prospective, Randomized Study of Its Use

Enderson, Blaine L.; Abdalla, René Jorge; Frame, Scott B.; Casey, Michael A.; Gould, Howard R.; Maull, Kimball I.

doi:10.1097/00005373-199207000-00044

Cited by 74 publications

(109 citation statements)

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“…While some studies suggest that patients may be observed without tube thoracostomy even while receiving positive-pressure ventilation, 5,23 other studies describe expansion of occult pneumothoraces and progression to tension physiology when conservatively managed in patients receiving positive pressure ventilation. 24 At this point, there is insufficient evidence to suggest that radiooccult pneumothoraces are of no clinical significance.…”

Section: Applying the Evidencementioning

confidence: 99%

Sensitivity of Bedside Ultrasound and Supine Anteroposterior Chest Radiographs for the Identification of Pneumothorax After Blunt Trauma

Wilkerson

Stone

2010

Academic Emergency Medicine

250

117

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Objectives: Supine anteroposterior (AP) chest radiographs in patients with blunt trauma have poor sensitivity for the identification of pneumothorax. Ultrasound (US) has been proposed as an alternative screening test for pneumothorax in this population. The authors conducted an evidence-based review of the medical literature to compare sensitivity of bedside US and AP chest radiographs in identifying pneumothorax after blunt trauma.Methods: MEDLINE and EMBASE databases were searched for trials from 1965 through June 2009 using a search strategy derived from the following PICO formulation of our clinical question: patients included adult (18 + years) emergency department (ED) patients in whom pneumothorax was suspected after blunt trauma. The intervention was thoracic ultrasonography for the detection of pneumothorax. The comparator was the supine AP chest radiograph during the initial evaluation of the patient. The outcome was the diagnostic performance of US in identifying the presence of pneumothorax in the study population. The criterion standard for the presence or absence of pneumothorax was computed tomography (CT) of the chest or a rush of air during thoracostomy tube placement (in unstable patients). Prospective, observational trials of emergency physician (EP)-performed thoracic US were included. Trials in which the exams were performed by radiologists or surgeons, or trials that investigated patients suffering penetrating trauma or with spontaneous or iatrogenic pneumothoraces, were excluded. The methodologic quality of the studies was assessed. Qualitative methods were used to summarize the study results. Data analysis consisted of test performance (sensitivity and specificity, with 95% confidence intervals [CIs]) of thoracic US and supine AP chest radiography.Results: Four prospective observational studies were identified, with a total of 606 subjects who met the inclusion and exclusion criteria. The sensitivity and specificity of US for the detection of pneumothorax ranged from 86% to 98% and 97% to 100%, respectively. The sensitivity of supine AP chest radiographs for the detection of pneumothorax ranged from 28% to 75%. The specificity of supine AP chest radiographs was 100% in all included studies.Conclusions: This evidence-based review suggests that bedside thoracic US is a more sensitive screening test than supine AP chest radiography for the detection of pneumothorax in adult patients with blunt chest trauma.

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Section: Applying the Evidencementioning

confidence: 99%

Sensitivity of Bedside Ultrasound and Supine Anteroposterior Chest Radiographs for the Identification of Pneumothorax After Blunt Trauma

Wilkerson

Stone

2010

Academic Emergency Medicine

250

117

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“…Intuitively, PPV would mandate prophylactic TT to prevent enlargement of a PTX or progression to a tension PTX. Two decades ago, Enderson et al 8 performed the first randomized controlled trial comparing TT (n = 19) and observation (n = 21) in patients with an occult PTX. In the observation arm, eight patients on PPV (38%) required TT due to progression of the PTX, and so the authors advised to perform TT in these patients on PPV.…”

Section: Resultsmentioning

confidence: 99%

“…Definimos el tratamiento como exitoso o fallido; si el neumotórax creció o hubo algún deterioro fisiológico del paciente que finalmente requirió el uso de sonda pleural, fue considerado como fallido. [1][2][3] Research Assistant, [4][5][6] Assistant Professor, 7 Professor 8 Associate Professor [1][2][3][4][5][6][7][8] Department of Surgery, Massachusetts General Hospital Boston, MA, USA Resultados: De un total de 165 pacientes con neumotórax, 17 (10.3%) midieron >35 mm y 148 (89.7%) midieron <35 mm. De los 17 >35 mm, 15 (88.7%) fueron tratados inmediatamente con sonda pleural.…”

Section: Materiales Y Métodosunclassified

Pneumothoraces on Computed Tomography Scan: Observation using the 35 Millimeter Rule is Safe

Cropano¹,

Mesar²,

Turay³

et al. 2015

Panamerican Journal of Trauma, Critical Care &Amp; Emergency Surgery

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Introduction:The management of a pneumothorax (PTX) either by observation or with a tube thoracostomy (TT) has long been dictated by practitioner discretion rather than objective criteria. Many physicians elect to routinely place a TT for traumatic PTX, particularly when patients undergo positive pressure ventilation (PPV). Placement of unnecessary TT exposes patients to avoidable morbidity and may prolong hospitalization. Based on prior work establishing a cutoff, we hypothesized that all PTXs ≤ 35 mm in patients who have no physiologic derangement may be safely observed without TT regardless of the need for PPV. Materials and methods:Retrospective review of all patients diagnosed with a PTX between 1/2009 and 2/2013. All PTXs visible on chest computed tomography (CT) were identified. Any patient with an associated significant hemothorax or those patients who were moribund were excluded. All PTXs were measured by measuring the perpendicular distance of the largest air pocket between the chest wall and the mediastinal or pulmonary structure. Management of the PTX was categorized as observation or TT. Observed PTXs were labeled as success or failure with failure defined as enlargement of the PTX or physiologic deterioration, requiring a TT.Results: Out of 165 PTXs, 17 (10.3%) measured >35 mm, whereas 148 (89.7%) measured ≤35 mm. Of the 17 > 35 mm, 15 (88.2%) received immediate TT. Of the two PTXs >35 mm which were observed, one received a delayed TT for a pleural effusion (6 days after PTX diagnosis) and one (5.9 %) was safely observed. Of the 148 PTXs which measured ≤ 35 mm, 10 (6.8%) received immediate TT. Of the 138 remaining PTXs, 129 (93.5%) were safely managed without TT. Six (4.3%) of the PTXs initially observed eventually required TT placement for enlargement of the PTX. Only one of those six had manifested ongoing desaturations prior to TT. The remaining three cases received TT for reasons unrelated to the PTX. Of the 27 PPV cases in the ≤35 mm cohort, none contributed to the six failures. A cutoff measurement of 35 mm demonstrated a negative predictive value (NPV) of 95.7% in its ability to predict successful observation of the PTX with an area under the receiver operating characteristic (ROC) curve of 0.90. Conclusion:All PTXs measuring ≤35 mm perpendicular to the chest wall without physiologic derangement may be safely observed independent of the need for mechanical ventilation. Source of support: Nil Conflict of interest: None RESUMENIntroducción: El manejo del neumotórax, ya sea con observación clínica o con sonda pleural, se ha basado en el juicio clínico y no en criterios objetivos.

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“…A large-bore (28-36 F) chest tube may be introduced following this procedure for continuous drainage, which may serve not only for evacuation of air but also of blood; hemothorax may be present in up to 20 % of patients with chest trauma [7]. Although some reports recommend observation without placing a chest tube after needle aspiration in pneumothoraces classified by CT according to their size, from miniscule to limited anterior to anterolateral [8,9], there is ample evidence that after traumatic pneumothorax the possibility of developing a life-threatening tension pneumothorax is high, especially when general anesthesia or positive pressure ventilation will be administered [7,10,11]. Reluctance to place a chest tube stems from concerns related to increased pain, decreased lung expansion, and infection.…”

Section: Resuscitation Phasementioning

confidence: 99%

Thoracic and Abdominal Injuries

Capan

Miller

2014

Anesthesia for Trauma

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Injuries to the thorax and the abdomen-the torso-contribute significantly to trauma-related mortality and morbidity. While the vulnerability of the closely organized vital organs to injury in this region plays an important role in morbidity and mortality, the noncompressible nature of hemorrhage in this area also contributes immensely to otherwise preventable trauma deaths. While it is estimated that one fourth of trauma deaths is secondary to chest trauma alone and claims about 16,000 lives per year [1], hemorrhage in the torso (thorax, abdomen, and pelvis) also results in a mortality of as much as 70-80 % after otherwise survivable noncerebral and noncardiac injuries in both civilian and military populations [2]. The overall mortality from exsanguination, which remains second to central nervous system (CNS) injury as a cause of death, primarily originates from injuries of the thorax, abdomen, and pelvis; there has been a reduction in death from extremity bleeding because of effective control with tourniquets or topical hemostatic agents, but not from torso bleeding. With increasing use of anticoagulant agents for prophylaxis and management of cardio-and cerebrovascular disorders, bleedingrelated mortality from truncal injuries is probably more frequent. For example, the predominant injury site in patients with cardiovascular disease who died after trauma in one study was chest in 15 % and abdomen in 3 % of instances; head and neck was the injury site in 69 % of patients [3].In 2008, of the more than 42 million injuryrelated emergency room visits in the United States only 4 % were due to torso injuries; the corresponding percentages for upper extremity injuries, lower extremity injuries, head and neck injuries, and vertebral injuries were 18 %, 15 %, 14 %, and 5 %, respectively [4]. Other diagnoses such as poisoning, adverse effects, ill-defined conditions, and mental disorders made up the remaining injury-related emergency room admissions [4]. Thus, although torso injuries represent a relatively small percentage of the emergency room load, they appear to cause a greater proportion of morbidity and mortality than other injuries.Up to 80 % of thoracic injuries coexist with other injuries in major trauma patients, but they require major surgery and anesthesia relatively infrequently. Yet undetected, relatively minor thoracic injuries may result in life-threatening events during surgery for associated injuries or intensive care management of the multiple trauma patient. Pneumothorax and hemothorax are perfect examples of this clinical situation. On the other hand, because of their sometimes silent nature, even major thoracic injuries (e.g., esophageal, diaphragmatic, and airway trauma) may be missed if appropriate diagnostic

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Tube Thoracostomy for Occult Pneumothorax-a Prospective, Randomized Study of Its Use

Cited by 74 publications

References 0 publications

Sensitivity of Bedside Ultrasound and Supine Anteroposterior Chest Radiographs for the Identification of Pneumothorax After Blunt Trauma

Sensitivity of Bedside Ultrasound and Supine Anteroposterior Chest Radiographs for the Identification of Pneumothorax After Blunt Trauma

Pneumothoraces on Computed Tomography Scan: Observation using the 35 Millimeter Rule is Safe

Thoracic and Abdominal Injuries

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