Pneu Concepts in Pneumothorax
Tobias Lindner
Emergency Dpt.- Trauma Wing
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Diagnostics ….. WHAT DO WE HAVE ?
 clinicial examination
 chest film
 ultrasound
 CT
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Diagnostics …..clinical examination
auscultation alone is not reliable !
 118 patients, penetrating chest injury
 71 (60%) with Ptx
 30 of these (42%) not diagnosed by inhospital
auscultation !
(control: chest radiograph !)
Chen et al. : Hemopneumothorax missed by auscultation in penetrating
chest injury. J Trauma. 1997
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Diagnostics ….. chest film……
….. there is a problem: occult pneumothorax
 109 patients after chest trauma
 only 13 of 25 PTXs detected by
supine ap chest film (control: CT)
 sensitivity 52%, specifity 100 %
Soldati et al. : Occult traumatic pneumothorax: diagnostic accuracy
of lung ultrasonography in the emergency department. Chest. 2008
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Diagnostics ….. chest film……
blunt chest trauma, cyclist hit by car
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Diagnostics ….. chest film……
blunt chest trauma, pedestrian hit by metal from lorry
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Diagnostics ….. ultrasound…….
M- mode, sliding lung sign
B- mode
seahore- sign
comet- trail- artifacts
stratosphere- sign
reverberations
Ouellet J-F et al., The sonographic diagnosis of pneumothorax. J
Emerg Trauma Shock. 2011
Stone MB et al., The heart point sign: description of a new ultrasound
finding suggesting pneumothorax.
Acad Emerg Med. 2010
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Diagnostics ….. ultrasound…….
 M- and B- mode, 3 min. per side, convex
probe
 operators at least 1 year experience (ER
personnel)
 23 of 25 PTXs detected by ultrasound
(remember: only 13 by ap chest film !)
 92 % sensitivity, 99.4 % specifity, NPV 98,9
Soldati et al. , Occult traumatic pneumothorax: diagnostic accuracy
of lung ultrasonography in the emergency department. Chest. 2008
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Diagnostics ….. ultrasound……
 evidence based review (chest ap radiograph vs US)
 4 prospective studies, gold standard: CT
 606 patients, blunt trauma cases
 US: sensitivity 86- 98 %, specifity 97- 100 %
 chest ap supine: sensitivity 28-75 %, specifity
100 %
RG Wilkerson et al., Sensitivity of Bedside Ultrasound and Supine
Anteroposterior Chest Radiographs for the Identification of
Pneumothorax After Blunt Trauma. Acad Emerg Med.. 2010
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Diagnostics ….. ultrasound……
Ding et al., CHEST. 2011
 20 studies, US: pooled sensitivity/ specifity = 88/ 99 %

(CR: pooled sensitivity/ specifity = 52/ 100 %)
bedside US performed by clinicians had higher sensitivity
and similar specificity compared to CR
 US depended on the skill of the operators
 US is reliable & advantage of portability, rapidity and non
biological invasive
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Diagnostics …..
however……….
does not favor ultrasound in diagnosing
spontaneous PTX – results too conflicting
(for them !)
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Diagnostics …..
......instead:
 standard
erect chest x- ray in inspiration (SP)
 lateral views might be helpful, but no routine
 expiratory films without additional benefit
 in doubt : CT
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Therapy…..Guidelines ?
Primary &
Secondary Spontaneous Pneumothorax
(PSP/SSP)
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&
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Therapy……PSP (small, stable)
 small* vs large
 small* vs large
 stable** vs unstable
clinical
compromise
observation
in ER for3-6
hrs.
breathlessness ? **
check x- ray
DISCHARGE
(if unchanged)
*apex/ cupula distance
< 3cm on chest film
*hilum to lateral chest wall <
**resp. rate < 24/ min., hr >
2 cm on chest film
60/ min. and < 120 /min., bp
**not definded
normal, O2 sat. room air >
92 %
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Therapy…..PSP (large, stable/unstable)
stable & large:
 small- bore catheter (<
14 F) or chest tube
(16-22F)
 discharge possible
with Heimlich valve
unstable & large:
 small- bore catheter
or chest tube
 admit !
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>2cm &/or breathless:
 needle aspiration
 discharge after
check x- ray
Therapy…….SSP
stable, small:
 observation or tube
 fatal cases during
observation reported !!!
(O´Rourke. Chest. 1989)
only in < 1 cm without compr.:
 consider observation or NA
all others:
 chest tube
2cm at level of hilum &/or
breathless:
 small bore catheter
 admit all !
 admit all !
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size 1-2 cm/ not breathless:
 needle aspiration
Bringing it together……
 (needle aspiration)
 small- bore catheter (< 14F)
 chest tube (16- 28F)
 needle aspiration 1st choice,
unless:
 bilateral PTX
 SSP and > 2cm at level of
hilum on CR
 small bore chest drains (8-14F)
(generally, no need for larger bore
catheters in all spontaneous PTX)
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NA vs Chest tube in PSP
 1 included study, total of 60 patients
 27 underwent simple aspiration
 33 underwent intercostal tube drainage
 no significant difference with regard to:
immediate, one week or one year success
rate
 simple aspiration is associated with a
reduction in hospitalization rate (53 vs 100 %)
Wakai et al., Simple aspiration versus intercostal tube drainage for
primary spontaneous pneumothorax in adults. Cochrane review. 2007.
Based on: Noppen 2002
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NA vs Chest tube in PSP
 review
 NA as safe and successful as tube thoracostomy
 fewer hospital admissions after NA
 shorter hospital stays (if admitted)
Zehtabchi et al., Management of Emergency Medicine Department Patients
With Primary Spontaneous Pneumothorax : Needle Apsiration or Tube
Thoracostomy ? Ann of Emerg. Med.. 2008.
 review
 NA might fail in larger PTX
 also SSP studies included !
Chan et al. , The Role of Simple Aspiration in the Management of Primary
Spontaneous Pneumothorax, J of Emerg. Med., 2008.
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general remarks:
 supplementary O2 therapy (at least 24 h)
- increases resolution rate by reduction of
nitrogen partial pressure
 no flights until then plus 1 week, but:
generally, recurrence risk drops sign. only after 1
year !
 no diving unless bilateral pleurodesis !
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chest drain removal:
 clamping is generally unnecessary
 period without suction before removal
 41 % of panel members do clamp
 all check CR before removal
 63 % after 13-23hrs after last evidence of
air leak
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Traumatic PTX
general remarks:
 2nd rank of injury after
chest trauma (after rib fx)
 relevant prehospital Dx !
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Diagnostics …..clinical examination
might be (more) reliable in trauma
than in spontaneous Ptx !
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Traumatic PTX- Diagnostics
 synopsis of auscultation, respiratory
rate /shortness of breath.
diagnostic accuracy can be improved by combining these
three signs…… (and putting hands on ! )
Waydhas et al.,Prehospital pleural decompression and
chest tube placement after blunt trauma: A systematic review.
Resuscitation. 2007.
 ……..but still: clinical examination is very variable…..
 ……. need of: safe, objective method independent
from setting
German Guideline on Polytraumamanagement- Prehospital Section, 2010
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Diagnostics ….. ultrasound……
 prehospital: possible as on scene method
but still
skill dependend !
Kirkpatrick et al. , Hand- Held Thoracic Sonography for
Detecting Post- Traumatic Pneumothoraces: The Extended
Focused Assessment With Sonography for Trauma. J of
Trauma. 2004
Walcher et al., Optimierung desTraumamanagements durch
präklinische Sonographie. Unfallchirurg. 2002
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Diagnostics …..what else is on the horizon ?
 micropower impulsed radar/ultrashort
radar pulse
 spatial accuracy of approx. 5mm
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Diagnostics …..what else is on the horizon ?
 portable/ point of care
 non- invasive
 easy
 1-2 min. scan time
 skin contact unnecessary
 penetrate through clothing
 ? specific location and volume ?
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Diagnostics …..what else is on the horizon ?
 promising !
 easy, quick, repeatable, not this operator
depended, objective !
 INDEPENDENT from preclinical setting !
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Therapy –Traumatic PTX
 should all be treated with
chest drains !
 air & blood !
 28- 36 F !
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Pneu Concepts in Pneumothorax
 US is accepted (in experienced operators
hands) for diagnosing PTX
 needle aspiration is the evolving method of
choice for active intervention in MOST
spontaneous PTx !?
 there is an urgent need for a easy &
objective tool for PTX diagnostics in the
prehospital setting !
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Danke !
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