Chest tube output, duration, and length of stay are similar for pneumothorax and hemothorax seen only on computed tomography vs. chest radiograph

Bhavesh H Patel, Christopher O Lew, Tanya Dall, Craig L Anderson, Robert Rodriguez, Mark I Langdorf, Bhavesh H Patel, Christopher O Lew, Tanya Dall, Craig L Anderson, Robert Rodriguez, Mark I Langdorf

Abstract

Purpose: Whole-body computed tomography (CT) for blunt trauma patients is common. Chest CT (CCT) identifies "occult" pneumo- (PTX) and hemothorax (HTX) not seen on chest radiograph (CXR), one-third of whom get chest tubes, while CXR identifies "non-occult" PTX/HTX. To assess chest tube value for occult injury vs. expectant management, we compared output, duration, and length of stay (LOS) for chest tubes placed for occult vs. non-occult (CXR-visible) injury.

Methods: We compared chest tube output and duration, and patient length of stay for occult vs. non-occult PTX/HTX. This was a retrospective analysis of 5451 consecutive Level I blunt trauma patients, from 2010 to 2013.

Results: Of these blunt trauma patients, 402 patients (7.4%) had PTX, HTX or both, and both CXR and CCT. One third (n = 136, 33.8%) had chest tubes placed in 163 hemithoraces (27 bilateral). Non-occult chest tube output for all patients was 1558 ± 1919 cc (n = 54), similar to occult at 1123 ± 1076 cc (n = 109, p = 0.126). Outputs were similar for HTX-only patients, with non-occult (n = 34) at 1917 ± 2130 cc, vs. occult (n = 54) at 1449 ± 1131 cc (p = 0.24). Chest tube duration for all patients was 6.3 ± 4.9 days for non-occult vs. 5.0 ± 3.3 for occult (p = 0.096). LOS was similar between all occult injury patients (n = 46) and non-occult (n = 90, 17.0 ± 15.8 vs. 13.7 ± 11.9 days, p = 0.23).

Conclusion: Mature clinical judgment may dictate which patients need chest tubes and explain the similarity between groups.

Keywords: Computed tomography; Thoracic; Trauma; Tube thoracostomy.

© 2019. Springer-Verlag GmbH Germany, part of Springer Nature.

References

    1. Rodriguez RM, Langdorf MI, Nishijima D, et al. Derivation and validation of two decision instruments for selective chest CT in blunt trauma: a multicenter prospective observational study (NEXUS Chest CT). PLOS Med. 2015;12:e1001883.
    1. American College of Surgeons Committee on Trauma. Secondary survey: potentially life-threatening injuries. In: Advanced trauma life support student course man, 9th edn, American College of Surgeons, Chicago; 2012. p. 103.
    1. Langdorf MI, Medak AJ, Hendey GW, et al. Prevalence and clinical import of thoracic injury identified by chest computed tomography but not chest radiography in blunt trauma: multicenter prospective cohort study. Ann Emerg Med. 2015;66:589–600.
    1. Lamb ADG, Qadan M, Gray AJ. Detection of occult pneumothoraces in the significantly injured adult with blunt trauma. Eur J Emerg Med. 2007;14:65–7.
    1. Hernandez MC, Zeb MH, Heller SF, et al. Tube thoracostomy complications increase cost. World J Surg. 2017;41:1482–7.
    1. Zhang M, Teo LT, Goh MH, et al. Occult pneumothorax in blunt trauma: is there a need for tube thoracostomy? Eur J Trauma Emerg Surg. 2016;42:785–90.
    1. Brasel KJ, Stafford RE, Weigelt JA, et al. Treatment of occult pneumothoraces from blunt trauma. J Trauma. 1999;46:987–91.
    1. Enderson BL, Abdalla R, Frame SB, et al. Tube thoracostomy for occult pneumothorax: a prospective randomized study of its use. J Trauma. 1993;35:726–30.
    1. Johnson G. Traumatic pneumothorax: is a chest drain always necessary? J Accid Emerg Med. 1996;13:173–4.
    1. Mahmood I, Tawfeek Z, Khoschnau S, et al. Occult hemopneumothorax following chest trauma does not need a chest tube. Eur J Trauma Emerg Surg. 2013;39:43–6.
    1. Llaquet Bayo H, Montmany Vioque S, Rebasa P, et al. Resultados del tratamiento conservador en pacientes con neumotórax oculto. Cirugía Española. 2016;94:232–6.
    1. Hefny A, Kunhivalappil F, Matev N, et al. Management of computed tomography-detected pneumothorax in patients with blunt trauma: experience from a community-based hospital. Singap Med J. 2018;59:150–4.
    1. Lee RKL, Graham CA, Yeung JHH, et al. Occult pneumothoraces in Chinese patients with significant blunt chest trauma: radiological classification and proposed clinical significance. Injury. 2012;43:2105–8.
    1. Kirkpatrick AW, Rizoli S, Ouellet J-F, et al. Occult pneumothoraces in critical care. J Trauma Acute Care Surg. 2013;74:747–55.
    1. Mahmood I, Abdelrahman H, Al-Hassani A, et al. Clinical management of occult hemothorax: a prospective study of 81 patients. Am J Surg. 2011;201:766–9.
    1. Mahmood I, Tawfeek Z, El-Menyar A, et al. Outcome of concurrent occult hemothorax and pneumothorax in trauma patients who required assisted ventilation. Emerg Med Int. 2015;2015:859130.
    1. Ball CG, Kirkpatrick AW, Feliciano DV. The occult pneumothorax: what have we learned? Can J Surg. 2009;52:E173–E179179.
    1. Gilbert EH, Lowenstein SR, Koziol-McLain J, et al. Chart reviews in emergency medicine research: where are the methods? Ann Emerg Med. 1996;27:305–8.
    1. Worster A, Bledsoe RD, Cleve P, et al. Reassessing the methods of medical record review studies in emergency medicine research. Ann Emerg Med. 2005;45:448–51.
    1. Chung M-H, Hsiao C-Y, Nian N-S, et al. The benefit of ultrasound in deciding between tube thoracostomy and observative management in hemothorax resulting from blunt chest trauma. World J Surg. 2018;42:2054–60.
    1. Moore FO, Goslar PW, Coimbra R, et al. Blunt traumatic occult pneumothorax: is observation safe?—results of a prospective, AAST multicenter study. J Trauma Inj Infect Crit Care. 2011;70:1019–25.
    1. Bailey RC. Complications of tube thoracostomy in trauma. J Accid Emerg Med. 2000;17:111–4.
    1. Demetri L, Martinez Aguilar MM, Bohnen JD, et al. Is observation for traumatic hemothorax safe? J Trauma Acute Care Surg. 2018;84:454–8.
    1. Hernandez MC, El Khatib M, Prokop L, et al. Complications in tube thoracostomy. J Trauma Acute Care Surg. 2018;85:410–6.
    1. Stawicki SA, Kwiatt M, Tarbox A, et al. Thoracostomy tubes: a comprehensive review of complications and related topics. Int J Crit Illn Inj Sci. 2014;4:142.
    1. Remérand F, Luce V, Badachi Y, et al. Incidence of chest tube malposition in the critically Ill. Anesthesiology. 2007;106:1112–9.
    1. Collop NA, Kim S, Sahn SA. Analysis of tube thoracostomy performed by pulmonologists at a teaching hospital. Chest. 1997;112:709–13.
    1. Etoch SW, Bar-Natan MF, Miller FB, et al. Tube thoracostomy. Factors related to complications. Arch Surg. 1995;130:521–5 (discussion 525–526).
    1. Helling TS, Gyles NR, Eisenstein CL, et al. Complications following blunt and penetrating injuries in 216 victims of chest trauma requiring tube thoracostomy. J Trauma. 1989;29:1367–70.
    1. Mowery NT, Gunter OL, Collier BR, et al. Practice management guidelines for management of hemothorax and occult pneumothorax. J Trauma Inj Infect Crit Care. 2011;70:510–8.
    1. Bilello JF, Davis JW, Lemaster DM. Occult traumatic hemothorax: when can sleeping dogs lie? Am J Surg. 2005;190:841–4.
    1. Karmy-Jones R, Holevar M, Sullivan RJ, et al. Residual hemothorax after chest tube placement correlates with increased risk of empyema following traumatic injury. Can Respir J. 2008;15:255–8.
    1. DuBose J, Inaba K, Demetriades D, et al. Management of post-traumatic retained hemothorax. J Trauma Acute Care Surg. 2012;72:11–24.
    1. Mergo PJ, Helmberger T, Didovic J, et al. New formula for quantification of pleural effusions from computed tomography. J Thorac Imaging. 1999;14:122–5.
    1. de Moya MA, Seaver C, Spaniolas K, et al. Occult pneumothorax in trauma patients: development of an objective scoring system. J Trauma Inj Infect Crit Care. 2007;63:13–7.
    1. Collins JC, Levine G, Waxman K. Occult traumatic pneumothorax: Immediate tube thoracostomy versus expectant management. Am Surg. 1992;58:743–6.
    1. Ball CG, Kirkpatrick AW, Laupland KB, et al. Incidence, risk factors, and outcomes for occult pneumothoraces in victims of major trauma. J Trauma. 2005;59:917–24 (discussion 924–925).
    1. Garramone RR Jr, Jacobs LM, Sahdev P. An objective method to measure and manage occult pneumothorax. Surg Gynecol Obs. 1991;173:257–61.
    1. Barrios C, Tran T, Malinoski D, et al. Successful management of occult pneumothorax without tube thoracostomy despite positive pressure ventilation. Am Surg. 2008;74:958–61.
    1. Kaiser M, Whealon M, Barrios C, et al. The clinical significance of occult thoracic injury in blunt trauma patients. Am Surg. 2010;76:1063–6.
    1. Wilson H, Ellsmere J, Tallon J, et al. Occult pneumothorax in the blunt trauma patient: tube thoracostomy or observation? Injury. 2009;40:928–31.

Source: PubMed

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