Management of traumatic occult pneumothorax

Abstract

Study objective: Occult pneumothorax (OPTX) is defined as a pneumothorax seen on computed tomography but not apparent on supine plain radiography. Though increasingly common, the acute management of OPTX after trauma remains controversial. This evidence-based review evaluates the existing evidence regarding the safety and efficacy of observation as compared to tube thoracostomy (TT) for management of OPTX in emergency department trauma patients.

Methods: The authors searched MEDLINE, EMBASE, the Cochrane Library, and other databases.

Inclusion criteria: studies of adult or pediatric trauma victims at first presentation after blunt or penetrating injury (population), randomized to observation (intervention) or TT (comparison). Studies that enrolled patients on positive pressure ventilation were included but those that enrolled hemodynamically unstable patients were excluded. Outcomes of interest included progression of OPTX, mortality, complications (pneumonia, empyema), and length of stay in hospital and intensive care unit (ICU).

Results: A total of 411 articles were identified. After applying the inclusion/exclusion criteria, 3 randomized trials enrolling a total of 101 patients were found to have acceptable quality standards suitable for analysis. The included studies did not reveal any significant difference between observation and TT in regards to progression of OPTX, risk of pneumonia, or length of stay in hospital or ICU. Mortality risk and empyema rate were also not different in the single studies that reported those outcomes.

Conclusion: The existing evidence leads to the conclusion that observation is at least as safe and effective as tube thoracostomy for management of occult pneumothorax.