Is a chest drain necessary in stable patients with traumatic pneumothorax?
Date First Published:
May 12, 2005
Last Updated:
August 14, 2008
Report by:
Linda Symington, Specialist Registrar (Ninewells Hospital, Dundee)
Search checked by:
Elizabeth McGugan, Ninewells Hospital, Dundee
Three-Part Question:
In [stable patients with traumatic pneumothorax] is [withholding chest drain insertion] a [safe and effective treatment option]?
Clinical Scenario:
A patient presents to the emergency department following an isolated chest injury. He is not dyspnoeic and recorded observations are normal but chest xray demonstrates a simple pneumothorax. You wonder does this patient require formal chest drain insertion or can he be treated conservatively?
Search Strategy:
Ovid MEDLINE(R) 1950 to February Week 4 2008 and EMBASE 1980 to 2008 Week 10
Search Details:
[exp pneumothorax] AND [exp wounds and injuries OR trauma mp OR thoracic injuries] AND [exp thoracostomy OR exp chest tubes OR exp drainage] AND [exp Emergency Service, Hospital/or emergency department.mp OR injury.jx. OR trauma.jx. OR emergency.jx.] LIMIT to human AND English. AND publication year 2005–2008. The Cochrane Library Issue 1 2008. MeSH descriptor Pneumothorax explode all trees AND MeSH descriptor Chest Tubes explode all trees 31 records none relevant.
Outcome:
A total of 524 unique papers was identified from Medline and from Embase of which three were relevant
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Traumatic Pneumothorax:a scheme for rapid patient turnover. Knottenbelt JD, van der Spuy JW. 1990 South Africa | 333 patients with pure unilateral PTX, lung border less than 1.5 cm from chest wall at 3rd rib, not requiring IPPV, no underlying lung disease treated expectantly studied | Case series / Prospective observational study of new protocol | Progression to chest drainage | 8.8% (6/333) required chest drain for radiological progression | No control group Rates of complications at follow-up not divided into groups treated expectantly or by thoracostomy tttttMajority of patients with penetrating wounds may not be reflective of other populations |
| Clinical deterioration | No clinical deterioration in group treated expectantly | ||||
| Traumatic pneumothorax: is a chest drain always necessary? Johnson G. May-96 United Kingdom | 53 patients with a diagnosis of traumatic PTX found on department database 29 managed expectantly, 24 by thoracostomy 49 post blunt trauma, 4 penetrating trauma |
Retrospective case note review | Progression to chest drain | 7% (2/29) required chest drain for asymptomatic radiographic progression | Retrospective. No control group. No protocol for choice of treatment - at physician discretion. Length of follow up not specified. |
| Clinical deterioration | No clinical deterioration in group treated expectantly | ||||
| Catheter Aspiration for Simple Pneumothorax (CASP) in the Outpatient Management of Simple Traumatic Pneumothorax. Obeid FN, Shapiro MJ, Richardson HH, Horst HM, Bivins BA. Sep-85 US | 34 patients simple traumatic PTX, haemodynamically stable, no other clinically significant injury, no underlying lung disease treated by catheter aspiration or thoracostomy 4 post blunt trauma, 21 iv drug injection, 9 penetrating trauma Patients matched to control patients treated with thoracostomy prior to study |
Prospective trial of aspiration | Progression to chest drain | 6% (1/17) required chest drain for failure of aspiration | Small numbers. Not randomised. Control group not studied prospectively. High incidence of iv drug use as aetiology – may not be reflective of other populations |
| Clinical deterioration | No clinical deterioration in group treated by aspiration |
Author Commentary:
No prospective, randomised controlled trials were found comparing observation or catheter aspiration with thoracostomy in traumatic pneumothorax but these papers indicate that conservative treatment can be undertaken in some patients. Selected patients would have to be haemodynamically stable with no respiratory compromise and not requiring IPPV. A robust protocol for determining patient selection and appropriate observation and follow up would be useful.
Bottom Line:
Although the available evidence is limited, it appears some stable patients with simple traumatic pneumothorax can be safely and effectively treated without chest drain insertion.
References:
- Knottenbelt JD, van der Spuy JW.. Traumatic Pneumothorax:a scheme for rapid patient turnover.
- Johnson G.. Traumatic pneumothorax: is a chest drain always necessary?
- Obeid FN, Shapiro MJ, Richardson HH, Horst HM, Bivins BA.. Catheter Aspiration for Simple Pneumothorax (CASP) in the Outpatient Management of Simple Traumatic Pneumothorax.