| Background |
Traumatic pneumothoraces are a common consequence of major trauma; however, there is sparse literature regarding optimal management of pneumothoraces, including the role of conservative treatment. |
| Rational and Objective |
The aim of this study was to determine outcomes of conservatively managed human patients and determine whether there are factors that can help predict the need for chest tube placement. |
| Trial Design |
Observational Study |
| Patient population and location |
Regional UK adult major trauma center. 3761 trauma patients; 602 with pneumothoraces included for analysis |
| Methods |
- Patients were identified as part of the Trauma Audit and Research Network (TARN) of patients presenting to the emergency department of a regional UK adult major trauma center (MTC). The TARN database includes all trauma patients irrespective of age who have a direct admission or are transferred to a member hospital and whose length of stay is ≥ 3 days. Certain specific injuries were excluded, including isolated femoral neck fractures or intertrochanteric/greater trochanteric fractures in persons > 65 years.
- The size of the pneumothorax was obtained from chest radiographs at the hilum and apex, and on computed tomography, measuring a line from the chest wall to the lung.
- Descriptive statistics were used to summarize patient characteristics and clinical data. Continuous parametric variables were analyzed using independent t tests, and continuous nonparametric variables were analyzed using the Mann-Whitney test. Categorical data were analyzed using the c2 test. P < .05 was considered statistically significant.
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| Results |
602 with pneumothoraces
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- Mean age was 48 years, 73% were men.
- 55% received their injuries as a result of road traffic accidents.
- The mean Injury Severity Score (ISS) was 26, representing very severe injuries.
- 31% required immediate invasive ventilation.
- 9% died during admission.
- 54% had an intervention performed before hospital admission or on admission, which included needle decompression, chest tube insertion, or chest surgery.
- 46% were initially treated conservatively. The patients who were managed conservatively had significantly smaller pneumothoraces compared with the patients managed with immediate interventions (median, 5.5 mm versus 22 mm), with the majority of lesions < 10 mm.
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| Limitations |
This was a single center study with a low rate of penetrating chest wall injuries (5%).
The decision to intervene may have affected the conservatively treated cohort characteristics, and it is likely that high-risk unwell patients were underrepresented in the conservatively treated arm.
Those treated with an immediate intervention, despite a similar ISS, likely represented a more unwell population, with higher rates of cardiorespiratory compromise, use of positive pressure ventilation (PPV), surgical referral, and mortality.
The length of stay criteria is likely to have been biased against patients conservatively managed successfully and not requiring a prolonged hospital admission, suggesting that the overall rate of effective conservative management is probably greater.
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| Clinical Relevance and Conclusions |
- The majority of conservatively managed patients were successfully managed without requiring a chest tube.
- This includes the majority of patients receiving PPV, the use of which did not present an increased risk of failure of expectant management.
- This study provides support for an observational approach if the treating physician does not believe that an immediate chest tube is warranted in a patient with a traumatic pneumothorax.
- Future prospective randomized trials examining the outcomes of a conservative approach in traumatic pneumothorax, regardless of pneumothorax size or use of PPV, would help clarify which patients are best managed conservatively without a chest tube.
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