In a patient who has sustained blunt trauma who is found to have an

occult pneumothorax on CT scan, is tube thoracostomy better than

observation at reducing morbidity and mortality?

Presented by: Abdulgadir F. Bugdadi

Occult Pneumothorax• A pneumothorax that is not suspected on the basis of

clinical examination or plain radiography but is ultimately detected with thoraco-abdominal computed tomography.

OCCULT PNEUMOTHORAX IN BLUNT TRAUMA PATIENT: TUBE THORACOSTOMY OR

OBSERVATION

• Study type :Retrospective review.

• Publishement :Injury – SEPTEMBER – 2009.

Objectives

Study conducted both to determine the incidence of OP and describe its current treatment status in blunt trauma population at a Canadian tertiary trauma

center, Of interest were therates of tube thoracostomy vs. observation without

chest drainage and their respective outcome

Methods• Data on all consecutive blunt trauma patients between

October 1994 and March 2003 was reviewed.

• Outcome measures evaluated ;1. Length of stay.2. Discharge status (Dead vs. Alive).3. Intervention and time of intervention (TT and its relation to PPV).

• Direct comparison bet. OP with TT group and OP without TT group… (in terms of baseline characteristics and outcome)

68 Occult pneumothoraces RESULTS33 No TT

(Observation)35 Tube

Thoracostomy

16 (48.4%) 29 (82.8%) Positive pressure ventilation

22.39 25.80 Similar

Mean injury severity score (ISS)

10 days 17.4 daysDifferent

Length of stay

9.1% 11.4%Similar

Mortality

No Tension pneumothoraces

• The natural hx. Of OPTX in blunt trauma pts. at our institution appears to be one of uneventful resolution irrespective of ISS, PPV, or placement of thoracostomy tube.

• The study suggest an interesting hypothesis thatobservation of the blunt trauma patients with OPTX without tube thoracostomy may be safe and contribute to a shorter hospital stay.

Recommendation

These are observations that would benefit from further study in a large, prospective randomized controlled trial.

BLUNT TRAUMATIC OCCULT PNEUMOTHORAX:

IS OBSERVATION SAFE?

• Study type :Prospective, observational, multicenter study.

• Publishement :Journal of Trauma, infection and critical care – May - 2011

Objective

To determine which factors predicted failed observation in blunt trauma patients

Methods• Successfully observed patients and patients who failed

observation were compared.

588 OPTX

121( 21% )immediate TT

448( 79% )observed

588 OPTX

121( 21% )immediate TT

448( 79% )observed

27 (6%) failed observation and required TT (1)

Out of 73 pt. on PPV, 10 (14%) failed observation.

Rest did not fail observation

• Hospital and ICU lengths of stay, and ventilator days were longer in the failed observation group.

• OPTX progression and respiratory distress, significant predictors of failed observation.

• No patient who failed observation developed tension PTX, or experienced adverse events by delaying TT.

Conclusion

Most blunt trauma pt. with OPTX can be carefully monitored without TT; however, OPTX progression and

respiratory distress are independently associated with observation failure.

THE OPTICC TRIAL: A MULTI-INSTITUTIONAL STUDY OF

OCCULT PNEUMOTHORACES IN CRITICAL CARE

• Study type :Randomized trials.

• Publishement :American journal of surgery – 01 – may - 2009

objective

To address the feasibility and safety of randomizing traumatized patients undergoing PPV to drainage or observation.

Methods• Pts. randomized to observation (unless drainage became clinically

indicated) or to chest tube.

• 24 trauma pts. enrolled (2 excluded b/c final CT; no OPTX).

• Episodes of respiratory distress (need for TT, acute/sustained increase in oxygen requirements, difficulty in achieving adequate ventilation and self reported distress) and subsequent imaging abnormalities were recorded until discharge.

Drainage Observation

9 (41%) pts. 13 (59%) pts. Randomization

All pts. 4 pts. (31%) had CT placed non-urgently for worsening

OPTX/effusion.None with increased

morbidity

Chest tube

33% 41% Overall rates of respiratory distress

22% 15% Overall mortality

10 16 In hospital days

Results and Conclusion• Overall respiratory distress, mortality, in hospital days were

similar across groups.

• With no important difference in morbidity, OPTICC trial lays the foundation for future trial comparing drainage or observation in post-traumatic OPTX requiring PPV.

OCCULT PNEUMOTHORAX IN CHINESE PATIENTS WITH

SIGNIFICANT BLUNT CHEST TRAUMA: INCIDENCE AND

MANAGEMENT

• Study type :Prospective analysis of collected trauma registry.

• Publishement :Injury – 1- may – 2010.

Objective

To identify the incidence of OP using TCT as the gold standard and describes its management amongst Hong Kong Chinese

trauma patients.

Methods• Analysis of prospectively collected trauma registry data.

Consecutive significantly injured trauma patients admitted through ED suffering from blunt chest trauma who underwent TCT between calendar years 2007 and 2008 were included.

36 pts. With at least one OP.

Bilateral OP in 8/36. Total no.

were 44

8/44 had TTAll were

mechanically ventilated in ED

36 pts. Managed

expectantly

No pt. in the expectant group had pneumothorax progression (even though 8 pts. Required subsequent ventilation in the operating room for extrathoracic surgery)

Conclusion

Most OP were managed expectantly without significant complications; no pneumothorax progressed even though

some pts. Were mechanically ventilated.

Incidence of OP in Chinese pt. after blunt trauma is higher than the typically reported in Caucasians.

MANAGEMENT OF TRAUMATIC OCCULT

PNEUMOTHORAX

• Study type :evidence based review

• Publishement :Resuscitation – 01 – September - 2010

Objective

To evaluate 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• 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. Randomized to observation or TT. Studies that enrolled pts. On PPV were included.

• Excluded studies :studies that enrolled hemodynamically unstable patients.

• Outcome of interest includes :progression of OPTX, mortality, complications (pneumonia, empyema), and length of stay in hospital and ICU.

• 411 articles identified. After application of inclusion and exclusion criteria, 3 randomized trials enrolling 101 patients were found to have acceptable quality standards suitable for analysis.

Results

Inclusion 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.

Conclusion

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

Answer

According to previous studies it appears thatTube Thoracostomy is NOT BETTER than

observation in reducing morbidity and mortality in a blunt trauma patient with occult

pneumothorax.

END

Thank You