Evaluation and management of traumatic pneumothorax: A Western Trauma Association critical decisions algorithm

Marc de Moya, MD, Karen J. Brasel, MPH, MD, Carlos V.R. Brown, MD, Jennifer L. Hartwell, MD, Kenji Inaba, MD, Eric J. Ley, MD, Ernest E. Moore, MD, Kimberly A. Peck, MD, Anne G. Rizzo, MD, Nelson G. Rosen, MD, Jason Sperry, MPH, MD, Jordan A. Weinberg, MD, and Matthew J. Martin, MD

DOI: 10.1097/TA.0000000000003411 2021 WTA ORAL J Trauma Acute Care Surg Volume 92, Number1

Background

Proposed algorithm to approach traumatic pneumothorax (PTX) with regards to chest tube placement

Rational and Objective

With increased use of computed tomography (CT) in people, higher sensitivity for diagnosing PTX has occurred that has resulted in trend towards observation versus automatic chest tube placement

Trial Design

Level V consensus after literature review

Patient Population & Location

Designed for human trauma patients adaptable to individual hospital or organization’s needs.

Methods

The (human) literature was reviewed after a search in PubMed and Google scholar using the following key words: pneumothorax, traumatic pneumothorax, trauma, thoracic trauma.

Endpoints (if applicable)

n/a

Results

Consensus from literature review

Watchful waiting is recommended for mild PTX (20% of chest volume correlated with 2 cm from wall to lung on chest radiograph and 3.5 cm on chest CT) if there is cardiovascular stability and imaging is repeated in 6 hours.
Positive pressure ventilation does not increase incidence of PTX during observation.
When there is cardiovascular instability, finger thoracostomy or needle decompression followed by chest tube placement is recommended.
If a chest tube is placed, the following is recommended:
- One dose of a prophylactic antibiotic is supported by studies looking at incidence of empyema and pneumonia after chest tube placement.
- Small chest tubes adequately address PTX and are less painful than large bore tubes.

Limitations

This is a human algorithm that may have limited applicability to veterinary patients due to anatomical and clinical differences.

Clinical Relevance & Conclusions

See Results for article conclusions with regards to people.
Knowledge gaps for consideration in veterinary patients include the following:
- Investigating the need for prophylactic antibiotic therapy for chest tube placement
- Comparison of small versus large chest tubes in traumatic PTX cases
- Imaging measurements of PTX that might predict the need for a chest tube
Clinical applicability to veterinary patients is questionable due to the following:
- Needle decompression without chest tube placement is a common practice in veterinary medicine whereas chest tube placement is considered a stabilization procedure in human beings.
- Incomplete mediastinum in veterinary patients versus human beings may play a role in pathophysiology and treatment.

Evaluation and management of traumatic pneumothorax: A Western Trauma Association critical decisions algorithm

Ⓒ 2025 Veterinary Committee on Trauma