Air Transport of Patients with Pneumothorax: Is Tube Thoracostomy Required Before Flight?

The efficacy of out-of-hospital needle and tube thoracostomy in major trauma victims

The purpose of this study was to evaluate the frequency of inadequate needle chest thoracostomy in the prehospital setting in trauma patients suspected of having a pneumothorax (PTX) on the basis of physical examination. This study took place at a level I trauma center. All trauma patients arriving via emergency medical services with a suspected PTX and a needle thoracostomy were evaluated for a PTX with bedside ultrasound. Patients too unstable for ultrasound evaluation before tube thoracostomy were excluded, and convenience sampling was used. All patients were scanned while supine. Examinations began at the midclavicular line and included the second through fifth ribs. If no sliding lung sign (SLS) was noted, a PTX was suspected, and the lung point was sought for definitive confirmation. When an SLS was noted throughout and a PTX was ruled out on ultrasound imaging, the thoracostomy catheter was removed. Descriptive statistics were calculated. A total of 57 patients were evaluated over a 3-year period. All had at least 1 needle thoracostomy attempted; 1 patient underwent 3 attempts. Fifteen patients (26%) had a normal SLS on ultrasound examination and no PTX after the thoracostomy catheter was removed. None of the 15 patients were later discovered to have a PTX on subsequent computed tomography. In this study, 26% of patients who received needle thoracostomy in the prehospital setting for a suspected PTX appeared not to have had a PTX originally, nor had 1 induced by the needle thoracostomy. It may be prudent to evaluate such patients with bedside ultrasound instead of automatically converting all needle thoracostomies to tube thoracostomies.

Occult pneumothorax in the blunt trauma patient: Tube thoracostomy or observation?

Objective. Traumatic tension hemopneumothorax is fatal if not treated rapidly. However, whether prehospital decompression is better achieved by chest tube or needle thoracostomy is unknown. We conducted this study to compare the immediate results and prolonged effectiveness of two methods of treatment for traumatic tension hemopneumothorax in a swine model. Methods. Ten percent of calculated total blood volume was instilled into the hemithorax of spontaneously ventilating swine (n = 5 per group, 40 ± 3 kg). A Veres needle and insufflator were used to induce tension hemopneumothorax. Animals were randomized to one of four groups: 1) needle thoracostomy with 14-gauge intravenous catheter; 2) needle thoracostomy with Cook catheter; 3) 32-F chest tube thoracostomy; or 4) no intervention (control). Serial chest x-rays were obtained to document mediastinal shift before and after treatment. Arterial blood gas values and physiologic data were recorded. Postoperatively, thoracoscopy was performed to detect possible pulmonary injury from the procedure and/or catheter kinking or clotting. Results. Positive intrapleural pressure was rapidly relieved in all treated animals. Four-hour survival was 100% in the 14-gauge needle and chest tube thoracostomy groups, 60% in the Cook catheter group, and 0% in the control animals (p < 0.05). There were no significant differences in survival or physiologic measurements among the treated animals (p > 0.05). Conclusions. In this animal model, needle thoracostomy using a 14-gauge or Cook catheter was as successful as chest tube thoracostomy for relieving tension hemopneumothorax.

An occult pneumothorax (OPTX) is found incidentally in 2% to 10% of all blunt trauma patients. Indications for intervention remain controversial. We sought to determine which factors predicted failed observation in blunt trauma patients. A prospective, observational, multicenter study was undertaken to identify patients with OPTX. Successfully observed patients and patients who failed observation were compared. Multivariate logistic regression was used to identify predictors of failure of observation. OPTX size was calculated by measuring the largest air collection along a line perpendicular from the chest wall to the lung or mediastinum. Sixteen trauma centers identified 588 OPTXs in 569 blunt trauma patients. One hundred twenty-one patients (21%) underwent immediate tube thoracostomy and 448 (79%) were observed. Twenty-seven patients (6%) failed observation and required tube thoracostomy for OPTX progression, respiratory distress, or subsequent hemothorax. Fourteen percent (10 of 73) failed observation during positive pressure ventilation. Hospital and intensive care unit lengths of stay, and ventilator days were longer in the failed observation group. OPTX progression and respiratory distress were significant predictors of failed observation. Most patient deaths were from traumatic brain injury. Fifteen percentage of patients in the failed observation group developed complications. No patient who failed observation developed a tension PTX, or experienced adverse events by delaying tube thoracostomy. Most blunt trauma patients with OPTX can be carefully monitored without tube thoracostomy; however, OPTX progression and respiratory distress are independently associated with observation failure.

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 &gt;35 mm, whereas 148 (89.7%) measured ≤35 mm. Of the 17 &gt; 35 mm, 15 (88.2%) received immediate TT. Of the two PTXs &gt;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. How to cite this article Cropano C, Mesar T, Turay D, King D, Yeh D, Fagenholz P, Velmahos G, de Moya MA. Pneumothoraces on Computed Tomography Scan: Observation using the 35 Millimeter Rule is Safe. Panam J Trauma Crit Care Emerg Surg 2015;4(2):48-53.

Background: Pneumothorax (PTX) develops in 1–2% of neonates, leading to significant morbidity and mortality and requiring providers to be comfortable with management. Our objective was to evaluate whether radiographic measurements of PTX size can be used to predict the need for procedural intervention in neonates in order to help guide the need for the availability of specific personnel. Methods: With the help of a data analyst, 62 patients diagnosed with neonatal PTX between March 2016 and October 2024 were identified. Most babies (46) were born in 2023–2024 when our new electronic health record could more easily identify these infants. PTX size was evaluated using radiographs by calculating the ratio of the widest transverse measurement of the PTX on both anteroposterior (AP) and, when available, lateral decubitus (DECUB) divided by the widest transverse measurement of the hemithorax above the diaphragm. Clinical data were collected, and statistical analysis was performed using need for intervention (thoracentesis (TC), chest tube (CT), or both). Results: We found that a larger PTX size ratio, measured in the AP (p < 0.0001) or DECUB view (p < 0.008), was highly associated with need for intervention in this cohort of infants with PTX. Only 33% of PTXs required intervention. Also, 13/14 (93%) cases who underwent TC ultimately required a CT. PTX was more prevalent in males in general, but sex was not associated with needing intervention. The average gestational age (GA) of the cohort was 36 5/7 weeks, with only 12% being < 34 weeks GA. Univariate analysis indicated that lower GA and birth weight were risk factors for intervention. There was a trend (p = 0.075, by Fisher’s exact test) suggesting that infants with both respiratory distress syndrome (RDS) and PTX may be more likely (60%) to require intervention (no RDS, 29% intervention). Finally, a receiver operator characteristic curve was derived from the AP ratio based on the yes/no intervention which resulted in an area under the curve statistic of 0.902 and the optimal AP ratio cutoff of 0.184. Conclusions: The ratio of the transverse measurement of the PTX/hemithorax size from radiographs was highly predictive for need for intervention in a cohort of primarily term infants with PTX. Smaller and lower GA infants were at a higher risk for requiring procedural intervention. Nearly all infants who had TC also needed a CT. These findings could inform clinical strategies for managing neonatal PTXs, especially in identifying appropriate needed personnel availability if a TC occurs.

The incidence of occult pneumothorax (OPTX) has dramatically increased since the widespread use of computed tomography (CT) scanning. The OPTX is defined as a pneumothorax not identified on plain chest X-ray but detected by CT scan. The overall reported incidence is about 5% to 8% of all trauma patients. We conducted a 5-year review of our OPTX incidence and asked if an objective score could be developed to better quantify the OPTX. This in turn may guide the practitioner with the decision to observe these patients. This is a retrospective review of all trauma patients in a Level I university trauma center during a 5-year period. The patients were identified by a query of all pneumothoraces in our trauma registry. Those X-ray results were then reviewed to identify those who had OPTX. After developing an OPTX score on a small number, we retrospectively scored 50 of the OPTXs by taking the largest perpendicular distance in millimeters from the chest wall of the largest air pocket. We then added 10 or 20 to this if the OPTX was either anterior/posterior or lateral, respectively. A total of 21,193 trauma patients were evaluated and 1,295 patients with pneumothoraces (6.1%) were identified. Of the 1,295 patients with pneumothoraces, 379 (29.5%) OPTXs were identified. The overall incidence of OPTX was 1.8%: 95.7% occurred after blunt trauma, 222 (59%) of the OPTX patients had chest tubes and of the remaining 157 without chest tubes, 27 (17%) were on positive pressure ventilation. Of the 50 studies selected for scoring, the average score was 28.5. The average score for those with chest tubes was 34. The average score for those without chest tubes was 21. The positive predictive value for need of chest tube if the score was >30 was 78% and the negative predictive value if the score was <20 was 70%. Area under the receiver operator characteristic curve was 0.72, which was significant with p < 0.007. The OPTX score could quantify the size of the OPTX allowing the practitioner to better define a "small" pneumothorax. The management of OPTX is not standardized and further study using a more objective classification may assist the surgeon's decision-making. The application of a scoring system may also decrease unnecessary insertion of chest tubes for small OPTXs and is currently being prospectively validated.

Patients with an occult pneumothoraces (OPTXs) may be at risk of tension pneumothoraces (TPTXs) without drainage or pleural drainage complications if treated. Adults with traumatic OPTXs and requiring positive-pressure ventilation (PPV) were randomized to pleural drainage or observation (one side only enrolled if bilateral). All subsequent care and method of pleural drainage was per attending physician discretion. The primary outcome was a composite of respiratory distress (RD) (need for urgent pleural drainage, acute/sustained increases in O2 requirements, ventilator dysynchrony, and/or charted respiratory events). Ninety severely injured patients (mean [SD], Injury Severity Score [ISS], 33 [11]) were studied at four centers: Calgary (55), Toronto (27), Quebec (6), and Sherbrooke (3). Forty were randomized to tube thoracostomy, and 50 were randomized to observation. The risk of RD was similar between the observation and tube thoracostomy groups (relative risk, 0.71; 95% confidence interval, 0.40-1.27). There was no difference in mortality or intensive care unit (ICU), ventilator, or hospital days between groups. In those observed, 20% required subsequent pleural drainage (40% PTX progression, 60% pleural fluid, and 20% other). One observed patient (2%) undergoing PPV at enrollment had a TPTX, which was treated with urgent tube thoracostomy without sequelae. Drainage complications occurred in 15% of those randomized to drainage, while suboptimal tube thoracostomy position occurred in an additional 15%. There were three times (24% vs. 8%) more failures and more RDs (p = 0.01) among those observed with OPTXs requiring sustained PPV versus just for an operation, which increases threefold after a week in the ICU (p = 0.07). Our results suggest that OPTXs may be safely observed in hemodynamically stable patients undergoing PPV just for an operation, although one third of those requiring a week or more of ICU care received drainage, and TPTXs still occur. Complications of pleural drainage remain unacceptably high, and future work should attempt to delineate specific factors among those observed that warrant prophylactic drainage. Therapeutic study, level III.

Emergency Medical Services (EMS) clinicians manage patients with traumatic pneumothoraces. These may be simple pneumothoraces that are less clinically impactful, or tension pneumothoraces that disturb perfusion, lead to shock, and impart significant risk for morbidity and mortality. Needle thoracostomy is the most common EMS treatment of tension pneumothorax, but despite the potentially life-saving value of needle thoracostomy, reports indicate frequent misapplication of the procedure as well as low rates of successful decompression. This has led some to question the value of prehospital needle thoracostomy and has prompted consideration of alternative approaches to management (e.g., simple thoracostomy, tube thoracostomy). EMS clinicians must determine when pleural decompression is indicated and optimize the safety and effectiveness of the procedure. Further, there is also ambiguity regarding EMS management of open pneumothoraces. To provide evidence-based guidance on the management of traumatic pneumothoraces in the EMS setting, NAEMSP performed a structured literature review and developed the following recommendations supported by the evidence summarized in the accompanying resource document. NAEMSP recommends: EMS identification of a tension pneumothorax must be guided by a combination of risk factors and physical findings, which may be augmented by diagnostic technologies. EMS clinicians should recognize the differences in the clinical presentation of a tension pneumothorax in spontaneously breathing patients and in patients receiving positive pressure ventilation. EMS clinicians should not perform pleural decompression in patients with simple pneumothoraces but should perform pleural decompression in patients with tension pneumothorax, if within the clinician’s scope of practice. When within scope of practice, EMS clinicians should use needle thoracostomy as the primary strategy for pleural decompression of tension pneumothorax in most cases. EMS clinicians should take a patient-individualized approach to performing needle thoracostomy, influenced by factors known to impact chest wall thickness and risk for iatrogenic injury. Simple thoracostomy and tube thoracostomy may be used by highly trained EMS clinicians in select clinical settings with appropriate medical oversight and quality assurance. EMS systems must investigate and adopt strategies to confirm successful pleural decompression at the time thoracostomy is performed. Pleural decompression should be performed for patients with traumatic out-of-hospital circulatory arrest (TOHCA) if there are clinical signs of tension pneumothorax or suspicion thereof due to significant thoraco-abdominal trauma. Empiric bilateral decompression, however, is not routinely indicated in the absence of such findings. EMS clinicians should not routinely perform pleural decompression of suspected or confirmed simple pneumothorax prior to air-medical transport in most situations. EMS clinicians may consider placement of a vented chest seal in spontaneously breathing patients with open pneumothoraces. In patients receiving positive pressure ventilation who have open pneumothoraces, chest seals may be harmful and are not recommended. EMS physicians play an important role in developing curricula and leading quality management programs to both ensure that EMS clinicians are properly trained in the recognition and management of tension pneumothorax and to ensure that interventions for tension pneumothorax are performed appropriately, safely, and effectively.

The focused assessment with sonography for trauma (FAST) examination has become the standard of care for rapid evaluation of trauma patients. Extended FAST (eFAST) is the use of ultrasonography for the detection of pneumothorax (PTX). The exact sensitivity and specificity of eFAST detecting traumatic PTX during practical "real-life" application is yet to be investigated. This is a retrospective review of all trauma patients with a diagnosis of PTX, who were treated at a large level 1 urban trauma center from March 2013 through July 2014. Charts were reviewed for results of imaging, which included eFAST, chest X-ray, and CT scan. The requirement of tube thoracostomy and mechanism of injury were also analyzed. A total of 369 patients with a diagnosis of PTX were identified. A total of 69 patients were excluded, as eFAST was either not performed or not documented, leaving 300 patients identified with PTX. A total of 113 patients had clinically significant PTX (37.6%), requiring immediate tube thoracostomy placement. eFAST yielded a positive diagnosis of PTX in 19 patients (16.8%), and all were clinically significant, requiring tube thoracostomy. Chest X-ray detected clinically significant PTX in 105 patients (92.9%). The literature on the utility of eFAST for PTX in trauma is variable. Our data show that although specific for clinically significant traumatic PTX, it has poor sensitivity when performed by clinicians with variable levels of ultrasound training. We conclude that CT is still the gold standard in detecting PTX, and clinicians performing eFAST should have adequate training.

Summary The objective of this study was to assess the eti ology, diagnosis, treatment methods, surgical findi ngs, postoperative results and necropsy findings of seve nteen cases of thoracic trauma by evaluating medica l records. A car accident, falling down, stabbing and bites were identified as the causes of trauma. Dia gnosed pathologies in the cases included pneumothorax, hemothorax, pulmonary contusion, lung lobe collapse or eventration, rib fractures, etc. The treatment meth ods employed in these cases were medical therapy, thoracocentesis, tube thoracostomy, lateral interco stal thoracotomy, median sternotomy and thoracic wall revisions. Atelectasis, rupture, laceration or cont usion of the lung lobes, pulmonary artery rupture, rib fracture and etc. were the surgical findings. Overa ll, seven dogs and four cats recovered completely. Two dogs were euthanized due to other pathologies inclu ding multisegmental lumbar fracture, paraplegia and postpneumonectomy syndrome. Three dogs and a cat died during treatment management. The necropsies revealed that the animals had pulmonary artery and tracheobronchial ruptures. The cat also had sudden onset cardiac arrest during surgery. In conclusion, cases with thoracic trauma should be assessed closely an d managed with the necessary emergency and surgical procedures.

(Baraka) Professor and Chairman.Received from the Department of Anesthesiology, American University of Beirut, Beirut, Lebanon. Submitted for publication December 28, 1998. Accepted for publication March 18, 1999. Support was provided solely from institutional and/or departmental sources.Address reprint requests to Dr. Baraka: Department of Anesthesiology, American University of Beirut, Beirut, Lebanon.This article is accompanied by an Editorial View. Please see: Benumof JL: Airway exchange catheters: Simple concept, potentially great danger. Anesthesiology 1999; 91:342–4.BAROTRAUMA with resultant pneumothorax has been reported with transtracheal jet ventilation and with translaryngeal jet ventilation. [1–3] Tension pneumothorax also has been reported secondary to oxygen insufflation via an endotracheal tube during apnea testing to determine brain death. [4] The current report shows that a similar complication can follow oxygen jet ventilation via a Cook airway exchange catheter (Cook Critical Care, Ellettsville, IN).A 45-yr-old man who weighed 90 kg was scheduled for laparoscopic cholecystectomy. He had no preoperative cardiac or respiratory problems, and results of his chest radiograph were normal. Anesthesia was induced using thiopentone and fentanyl, and paralysis was induced using 0.1 mg/kg vecuronium. Laryngoscopy using a MAC3 blade only visualized the tip of the epiglottis. Glottic visualization was improved by cephalad, backward, and right displacement of the thyroid cartilage. However, the glottic view was still limited, and thus the trachea was intubated using a #6 ID oral endotracheal cuffed tube. Because of the patient's body weight, it was decided that the tube be changed to a larger size, using a Cook airway exchange catheter. The exchange catheter, with an internal diameter of 3 mm, was inserted into the tracheal tube and advanced until resistance was felt. This was interpreted as the carina. A high-pressure (50 pounds per square inch) oxygen source with a hand-controlled interrupter valve was connected to the proximal end of the exchange catheter via a Luer-lock adapter. Jet ventilation, consisting of 1-s bursts followed by 2 or 3 s of exhalation, was started. This resulted in visible inflation of the right chest but incomplete deflation. After only three jet pulses, cardiac asystole (isoelectric electrocardiograph) was noted. The development of tension pneumothorax was considered. The exchange catheter was withdrawn, and ventilation via the endotracheal tube and cardiopulmonary resuscitation were initiated. Chest auscultation revealed decreased air entry to the right lung. Needle thoracoscopy resulted in an audible escape of air and was followed by restoration of sinus rhythm. Cardiac arrest lasted 150 s. A right chest tube was inserted. Because of this complication, anesthesia and controlled ventilation were maintained via the original endotracheal tube throughout surgery. The patient recovered without complication.Intermittent oxygen jets (50 psi) via the lumen of an airway exchange catheter can result in barotrauma and tension pneumothorax. Passing a high-pressure oxygen jet through a narrow orifice creates a Venturi effect that results in air entrainment and a marked increase in the total flow. [5] The presence of the exchanger within the endotracheal tube can decrease significantly the cross-sectional area that impairs the passive exhalation, leading to air trapping with consequent barotrauma. In addition, the tip of the exchange catheter may wedge in a bronchus, thus obstructing air escape. Similar problems may occur when fiberoptic bronchoscopy is performed in patients whose tracheas are intubated; the introduction of the bronchoscope into the endotracheal tube can create a significant increase in airway resistance with a subsequent increase in the peak airway pressure. [6]The smaller the cross-sectional area of the endotracheal tube, and (or) the larger the external diameter of the bronchoscope or the exchange catheter inserted, the higher will be the resistance to exhalation. [6] Thus, a high flow of oxygen or oxygen jet ventilation delivered via the lumen of the catheter or the bronchoscope may result in barotrauma and catastrophic tension pneumothorax. Tension pneumothorax will displace the mediastinal structures and potentially decrease the venous return to the heart, resulting in cardiovascular collapse. Thus, the risk of barotrauma should be weighed carefully against the need for jet ventilation.To maintain oxygenation during tube exchange and minimize the risk of barotrauma, the following precautions are recommended.1. The patient must be adequately preoxygenated and hyperventilated by the original endotracheal tube using 100% oxygen.2. An exchange catheter must be selected that is proportional to the size of the endotracheal tube. If the catheter meets resistance, it should be withdrawn slightly.3. The clinician should consider maintaining oxygenation by administering a low flow of oxygen (1 or 2 1/min) via the lumen of the exchange catheter. This can provide adequate apneic diffusion oxygenation, because oxygen consumption in adults is only approximately 250 ml/min. Jet ventilation may not be necessary during the brief period of tube exchange, because the carbon dioxide tension increases during apnea at a rate of only 3 mmHg/min.4. Whenever jet ventilation is used, the incidence of complicating barotrauma may be decreased by minimizing airway pressure, providing a long expiratory time, and selecting a properly sized exchange catheter, all of which prevent air trapping. A catheter with multiple distal side holes also may decrease the pressure delivered at the distal end, minimize the catheter whip, and center the catheter within the trachea during jet ventilation. [3]

ENDOBRONCHIAL VALVES FOR TREATMENT OF PERSISTENT AIR LEAK AFTER SECONDARY SPONTANEOUS PNEUMOTHORAX IN PATIENTS WITH CYSTIC FIBROSIS

Occult pneumothorax is defined as a pneumothorax that is detected by abdominal computed tomographic (CT) scanning, but not routine supine screening chest roentgenograms. Forty trauma patients with occult pneumothorax were prospectively randomized to management with tube thoracostomy (n = 19) or observation (n = 21) without regard to the possible need for positive pressure ventilation, to test the hypothesis that tube thoracostomy is unnecessary in this entity. Eight of the 21 patients observed had progression of their pneumothoraces on positive pressure ventilation, with three developing tension pneumothorax. None of the patients with tube thoracostomy suffered major complications as a result of the procedure. Hospital and ICU lengths of stay were not increased by tube thoracostomy. Patients with occult pneumothorax who require positive pressure ventilation should undergo tube thoracostomy.