Which PTX Can Avoid a Chest Tube?

Written by Clay Smith

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Trauma patients with blunt (and maybe penetrating) chest injury, who had a pneumothorax (PTX) ≤35mm on CT did well without a thoracostomy tube (TT), with only 9% failing observation.

Why does this matter?
We find occult pneumothoraces more and more often on chest CT in trauma patients. Placing a chest tube is not without risk, with up to a 22% complication rate as well as increased pain, risk of infection, and longer hospital stay. How big a PTX is too big? Who needs a TT?

Which PTX is too big?
This was a retrospective, single-center study of 97% blunt trauma patients, 3% penetrating, who underwent chest CT. Of the 1,767 patients with chest trauma, 47% (832) had a PTX. On multivariate analysis, a PTX ≤35mm (largest identifiable pocket) on CT was highly associated with successful observation only and no TT, OR 0.142. This means the odds of needing a TT were reduced ~86% if the PTX was 35mm or less. The PPV for ≤35mm as the cutoff for successful observation, no TT, was 91%, meaning a 9% failure rate. Most who failed had progression in size or development of an effusion or hemothorax, though the reason for TT placement was unclear in almost half. The failure rate was 41% when the PTX was >35mm. Patients with hemothorax, who had a TT placed immediately or within 4 hours of presentation, or who were on positive pressure ventilation were excluded. Although this is encouraging, with a 9% failure rate, most patients with a small PTX still warrant observation in the hospital for a while.

Source
Observing Pneumothoraces: The 35 Millimeter Rule Is Safe for Both Blunt and Penetrating Chest Trauma. J Trauma Acute Care Surg. 2019 Jan 8. doi: 10.1097/TA.0000000000002192. [Epub ahead of print]

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Reviewed by Thomas Davis

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