From the Guidelines
Traumatic pneumothorax requires immediate medical attention, and treatment depends on the size and severity of the pneumothorax, with small cases potentially managed conservatively and larger cases typically requiring chest tube placement or surgical intervention. The management of traumatic pneumothorax is crucial to prevent complications such as tension pneumothorax, which is a medical emergency 1.
Diagnosis and Treatment
The diagnosis of traumatic pneumothorax involves identifying signs such as difficulty breathing, attenuated breath sound on the side of the injury, and elevated chest wall on the side of the injury 1. Treatment options include:
- Conservative management with supplemental oxygen and observation for small pneumothoraces
- Chest tube placement for larger pneumothoraces to remove accumulated air and allow lung re-expansion
- Surgical intervention for severe cases with ongoing air leaks or significant bleeding
Surgical Intervention
Surgical intervention may be necessary for severe cases of traumatic pneumothorax, and the optimal operation can be either resection of lung parenchyma or surgical pleurodesis to obliterate the pleural space 1. The choice of surgical procedure depends on the individual case and the surgeon's expertise.
Complications
Patients with traumatic pneumothorax should be monitored for complications such as tension pneumothorax, which requires immediate decompression with a needle or chest tube 1. The use of ultrasound in the diagnosis of tension pneumothorax has been shown to be effective, with high sensitivity and specificity 1.
Management in Special Situations
In the battlefield or other emergency situations, the management of traumatic pneumothorax may require adaptations, such as the use of a breathable chest pad to close open pneumothorax wounds or the performance of needle thoracentesis to decompress tension pneumothorax 1. The use of a one-way valve in the drainage tube may also be considered to increase the effectiveness of decompression.
From the Research
Diagnosis of Traumatic Pneumothorax
- Traumatic pneumothorax is a common pathology identified in the emergency department, and its diagnosis can be made using various methods, including chest x-ray (CXR), lung ultrasound (US), and computed tomography (CT) 2.
- Lung US has proven to be a potentially more useful tool in the detection of pneumothorax in the trauma bay compared with CXR, and has the potential to become the new gold standard for diagnosing traumatic pneumothorax 2.
- Computed tomography remains the ultimate gold standard, although in the setting of trauma, its utility lies more in confirming the presence and measuring the size of a pneumothorax 2.
Management of Traumatic Pneumothorax
- Traditional management of traumatic pneumothorax calls for chest x-ray (CXR) diagnosis and large-bore tube thoracostomy, although recent literature supports the efficacy of lung ultrasound (US) and more conservative approaches 2.
- The traditional mantra calling for large-bore chest tubes as first-line approaches to traumatic pneumothorax is challenged by recent literature demonstrating pigtail catheters as equally efficacious alternatives 2.
- In patients with small or occult pneumothoraces, even observation may be reasonable 2, 3.
- Needle decompression is a lifesaving procedure for tension pneumothorax, but its success depends on the length of the catheter, with longer catheters (4.5 cm) being more effective than shorter ones (3.2 cm) 4.
- Thoracic ultrasonography can be used to confirm needle decompression placement and diagnose pneumothorax 4, 3.
Complications and Considerations
- Complications of chest decompression are common and mainly include ectopic positions, which can jeopardize effectiveness of the procedure, sometimes fatal injuries to adjacent intrathoracic or - in case of too inferior placement - intraabdominal organs as well as hemorrhage or infections 5.
- Routine tube thoracostomy may not be necessary after prehospital needle decompression for tension pneumothorax, and patients can be assessed using chest radiography or thoracic computed tomography to determine the need for tube thoracostomy 6.