How To Predict the Need for Chest Tube in Occult Pneumothorax

Occult pneumothorax occurs somewhere between 2% and 12% in all blunt trauma patients. Many of these pneumothoraces never progress and thus never need treatment. Is there a way that we can identify ones that are likely to get worse?

A retrospective study of 283 blunt trauma patients with occult pneumothorax was presented at the EAST Annual Scientific Assembly last January. A total of 98 of these patients underwent chest tube insertion within 7 days, and 185 patients were successfully observed.

The authors noted an inverse relationship between age and successful conservative management. Patients with more serious injuries failed expectant management more frequently. Finally, patients with more rib fractures also tended to fail.

The authors estimated the risk of failure of expectant management based on these critieria and found:

  • Age > 35 – 36%
  • ISS > 24 – 20%
  • Rib fractures >= 4 – 53%

The risk with having none of these was 10%, and the risk with all was 75%! 

The time interval for placement was also interesting. 80% of the failures requiring a chest tube occurred within 24 hours, with most occurring in the first 2 hours. The authors also found that 40% of patients who were placed on a ventilator failed.

Obviously, this is a small retrospective study and the exact criteria for placing a chest tube were not specified. Nevertheless, it provides a simple tool that allows us to keep an eye on a subset of patients who are likely to fail observation of occult pneumothorax.

Reference: Factors Predicting Failed Observation of Occult Pneumothoraces in Blunt Trauma. Selander, Med Univ of South Carolina. EAST 2010 Annual Scientific Assembly.

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