Who Needs a Chest Tube? 35-mm Rule for Pneumothorax

Written by Vivian Lei

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Implementation of a guideline for chest tube placement with pneumothorax size cutoff of ≤35 mm in stable patients increased rates of observation for pneumothorax, with no apparent increase in rates of complication or observation failure.

Why does this matter?
Use of an objective measure to determine when a chest tube is necessary could help avoid unnecessary chest tubes and their complications. Earlier data show that patients with traumatic pneumothoraces ≤35mm seem to do well with observation only. This retrospective study demonstrates the effect of implementing a 35mm guideline on rates of observation and chest tube placement at a single center.

Too small to fail
In this single-center, retrospective study, researchers reviewed adult trauma patients diagnosed with pneumothorax on CT during a 2-year period of time before and after implementation of a new guideline to observe hemodynamically stable patients with pneumothoraces ≤35 mm. A total of 266 patients were included in the study. After guideline implementation in 2017, there was an increased in observation rates from 84.8% to 94.6% (p=0.007) and a corresponding decrease in number of patients receiving chest tubes from 28.3% to 18% (p=0.04). There was no significant difference in rates of observation failure (13%), length of hospital stay, complications, or mortality.

While the decision to observe patients with a small traumatic pneumothorax is not novel, the 35mm rule is an objective guideline that has already been implemented at the authors’ site and appears to be safe. Of course, entry into this guideline pathway required a chest CT, and it is unclear whether a CT would have been obtained if not to determine exact size of the pneumothorax.

The 35-mm Rule to Guide Pneumothorax Management: Increases Appropriate Observation and Decreases Unnecessary Chest Tubes. J Trauma Acute Care Surg. 2022 Feb 4. doi: 10.1097/TA.0000000000003573. Online ahead of print.

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