1887
Volume 2020, Issue 1
  • ISSN: 0253-8253
  • EISSN: 2227-0426

Abstract

We aimed to assess the management and outcome of occult pneumothorax and to determine the factors associated with failure of observational management in patients with blunt chest trauma (BCT). Patients with BCT were retrospectively identified from the trauma database over 4 years. Data were analyzed and compared on the basis of initial management (conservative vs. tube thoracostomy). Across the study period, 1928 patients were admitted with BCT, of which 150 (7.8%) patients were found to have occult pneumothorax. The mean patient age was 32.8 ± 13.7 years, and the majority were male (86.7%). Positive-pressure ventilation (PPV) was required in 32 patients, and bilateral occult pneumothorax was seen in 25 patients. In 85.3% (n = 128) of cases, occult pneumothorax was managed conservatively, whereas 14.7% (n = 22) underwent tube thoracostomy. Five patients had failed observational treatment requiring delayed tube thoracostomy. Pneumonia was reported in 12.8% of cases. Compared with those who were treated conservatively, patients who underwent tube thoracostomy had thicker pneumothoraxes and a higher rate of lung contusion, rib fracture, pneumonia, prolonged ventilatory days, and prolonged hospital length of stay. Overall mortality was 4.0%. The deceased had more polytrauma and were treated conservatively without a chest tube. Patients who failed conservative management had a higher frequency of lung contusion, greater pneumothorax thickness, higher Injury Severity Scores (ISS), and required more PPV. Occult pneumothorax is not uncommon in BCT and can be successfully managed conservatively with a close clinical follow-up. Intervention should be limited to patients who have an increase in size of the pneumothorax on follow-up or become symptomatic under observation. Patients who fail conservative management may have a greater pneumothorax thickness and higher ISS. However, large prospective studies are warranted to support these findings and to establish the institutional guidelines for the management of occult pneumothorax.

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2020-03-16
2024-03-29
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References

  1. Ball CG, Kirkpatrick AW, Laupland KB, Fox DI, Nicolaou S, Anderson IB, et al.  Incidence, risk factors, and outcomes for occult pneumothoraces in victims of major trauma. J Trauma. 2005; 59(4)::917-24; discussion: 924925.
    [Google Scholar]
  2. Chiles C, Ravin CE. Radiographic recognition of pneumothorax in the intensive care unit. Crit Care Med. 1986; 14::677680.
    [Google Scholar]
  3. Tocino IM, Miller MH, Fairfax WR. Distribution of pneumothorax in the supine and semirecumbent critically ill adult. Am J Roentgenol. 1985; 144::901905.
    [Google Scholar]
  4. Kurdziel JC, Dondelinger RF, Hemmer M. Radiological management of blunt polytrauma with CT and angiography: an integrated approach. Ann Radiol. 1987; 30::121124.
    [Google Scholar]
  5. Chen L, Zhang Z. Bedside ultrasonography for diagnosis of pneumothorax. Quant Imaging Med Surg. 2015; 5:4:618623.
    [Google Scholar]
  6. Ball CG, Kirkpatrick AW, Feliciano DV. The occult pneumothorax: what have we learned? Can J Surg. 2009; 52:5:E173E179.
    [Google Scholar]
  7. Ball CG, Hameed SM, Evans D, Kortbeek JB, Kirkpatrick AW. Canadian Trauma Trials Collaborative. Occult pneumothorax in the mechanically ventilated trauma patient. Can J Surg. 2003; 46:5:373379.
    [Google Scholar]
  8. Omar HR, Abdelmalak H, Mangar D, Rashad R, Helal E, Camporesi EM. Occult pneumothorax, revisited. J Trauma Manag Outcomes. 2010 Oct; 4::12.
    [Google Scholar]
  9. Ball CG, Lord J, Laupland KB, Gmora S, Mulloy RH, Ng AK, et al.  Chest tube complications: how well are we training our residents? Can J Surg. 2007; 50:6:450458.
    [Google Scholar]
  10. Mowery NT, Gunter OL, Collier BR, Diaz JJ Jr, Haut E, Hildreth A, et al.  Practice management guidelines for management of hemothorax and occult pneumothorax. J Trauma. 2011; 70:2:510518.
    [Google Scholar]
  11. American College of Surgeons Committee. Advanced trauma life support program for doctors. 9th ed. Chicago: American College of Surgeons 2013.
    [Google Scholar]
  12. Michaeli P, Munnangi S, Digiacomo JC, Gonzalez E, Catherine AMK. Factors associated with chest tube placement in blunt trauma patients with an occult pneumothorax. Crit Care Res Pract. 2019;2019.
    [Google Scholar]
  13. Hefny AF, Kunhivalappil FT, Matev N, Avila NA, Bashir MO, Abu-Zidan FM. Management of computed tomography-detected pneumothorax in patients with blunt trauma: experience from a community-based hospital. Singapore Med J. 2018; 59:3:150154.
    [Google Scholar]
  14. Fulton C, Bratu I. Occult pneumothoraces in ventilated pediatric trauma patients: a review. Can J Surg. 2015; 58:3:177180.
    [Google Scholar]
  15. Kirkpatrick AW, Rizoli S, Ouellet JF, Roberts DJ, Sirois M, Ball CG, et al.  Canadian Trauma Trials Collaborative and the Research Committee of the Trauma Association of Canada. Occult pneumothoraces in critical care: a prospective multicenter randomized controlled trial of pleural drainage for mechanically ventilated trauma patients with occult pneumothoraces. J Trauma Acute Care Surg. 2013; 74:3:74754, discussion 754-5.
    [Google Scholar]
  16. De Moya MA, Seaver C, Spaniolas K, Inaba K, Nguyen M, Veltman Y, et al.  Occult pneumothorax in trauma patients: development of an objective scoring system. J Trauma. 2007; 63::1317.
    [Google Scholar]
  17. Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC definitions for nosocomial infections. Am J Infect Control. 1988; 16::128140.
    [Google Scholar]
  18. Monaghan SF, Swan KG. Tube thoracostomy: the struggle to the standard of care. Ann Thorac Surg. 2008; 86:6:20192022.
    [Google Scholar]
  19. Deneuville M. Morbidity of percutaneous tube thoracostomy in trauma patients. Eur J Cardiothorac Surg. 2002; 22::673678.
    [Google Scholar]
  20. Guerrero-López F, Vazquez-Mata G, Alcazar-Romero PP, Fernández-Mondéjar E, Aguayo-Hoyos E, Linde-Valverde CM. Evaluation of the utility of computed tomography in the initial assessment of the critical care patient with chest trauma. Crit Care Med. 2000; 28::13701375.
    [Google Scholar]
  21. Brasel KJ, Stafford RE, Weigelt JA, Tenquist JE, Borgstrom DC. Treatment of occult pneumothoraces from blunt trauma. J Trauma. 1999; 46::987991.
    [Google Scholar]
  22. Hill SL, Edmisten T, Holtzman G, Wright A. The occult pneumothorax: an increasing entity in trauma. Am Surg. 1999; 65::254258.
    [Google Scholar]
  23. Collins JC, Levine G, Waxman K. Occult traumatic pneumothorax: immediate tube thoracostomy versus expectant management. Am Surg. 1992; 58::743746.
    [Google Scholar]
  24. Moore FO, Goslar PW, Coimbra R, Velmahos G, Brown CV, Coopwood TB Jr, et al.  Blunt traumatic occult pneumothorax: is observation safe?-results of a prospective, AAST multicenter study. J Trauma. 2011; 70:5:10191023, discussion 1023-5.
    [Google Scholar]
  25. Plurad D, Green D, Demetriades D, Rhee P. The increasing use of chest computed tomography for trauma: is it being over utilized? J Trauma. 2007; 62::631635.
    [Google Scholar]
  26. Enderson BL, Abdalla R, Frame SB, Casey MT, Gould H, Maull KI. Tube thoracostomy for occult pneumothorax: a prospective randomized study of its use. J Trauma. 1993; 35:5:726729, discussion 729-30.
    [Google Scholar]
  27. Bridges KG, Welch G, Silver M, Schinco MA, Esposito B. CT detection of occult pneumothorax in multiple trauma patients. J Emerg Med. 1993; 11:2:179186.
    [Google Scholar]
  28. Omert L, Yeaney WW, Protech J. Efficacy of thoracic computerized tomography in blunt chest trauma. Am Surg. 2001; 67::660667.
    [Google Scholar]
  29. Pinhu L, Whitehead T, Evans T, Griffiths M. Ventilator-associated lung injury. Lancet. 2003; 361:9354:332340.
    [Google Scholar]
  30. Pham T, Brochard LJ, Slutsky AS. Mechanical Ventilation: State of the Art. Mayo Clin Proc. 2017; 92:9:13821400.
    [Google Scholar]
  31. Barrios C, Tran T, Malinoski D, Lekawa M, Dolich M, Lush S, et al.  Successful management of occult pneumothorax without tube thorocostomy despite positive pressure ventilation. Am Surg. 2008; 74:10:958961.
    [Google Scholar]
  32. Pramod T, Shashirekha CA, Chandan KR, Harsha R. Role of conservative management of traumatic chest injuries: a retrospective study & review of literature. Int J Sci Stud. 2015; 3:8:147150.
    [Google Scholar]
  33. Yadav K, Jalili M, Zehtabchi S. Management of traumatic occult pneumothorax. Resuscitation. 2010; 81:9:10631068.
    [Google Scholar]
  34. Zhang M, Teo LT, Goh MH, Leow J, Go KT. Occult pneumothorax in blunt trauma: is there a need for tube thoracostomy? Eur J Trauma Emerg Surg. 2016; 42:6:785790.
    [Google Scholar]
  35. Lee KL, Graham CA, Yeung JHH, Ahuja AT, Rainer TH. Occult pneumothorax in Chinese patients with significant blunt chest trauma: incidence and management. Injury. 2010; 41::492494.
    [Google Scholar]
  36. Wilson H, Ellsmere J, Tallon J, Kirkpatrick A. Occult pneumothorax in the blunt trauma patient: tube thoracostomy or observation? Injury. 2009; 40:9:928931.
    [Google Scholar]
  37. Mahmood I, Tawfeek Z, El-Menyar A, Zarour A, Afifi I, Kumar S, et al.  Outcome of concurrent occult hemothorax and pneumothorax in trauma patients who required assisted ventilation. Emerg Med Int. 2015;2015.
    [Google Scholar]
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  • Article Type: Research Article
Keyword(s): chest CT scanchest traumaoccult pneumothorax and ventilation
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