Traumatic pneumothorax

Background

Types
  1. Open
    • Communication between pleural space and atmospheric pressure (sucking chest wound)
  2. Closed
  3. Occult

Clinical Features
  • Rib fracture and penetrating trauma most common causes
  • Isolated pneumothorax does not cause severe symptoms until >40% of hemithorax is occupied

Differential Diagnosis

Pneumothorax Types

Thoracic Trauma

Evaluation
  • Occult pneumothorax after a stab wound may be delayed for up to 6 hours
    • If patient decompensates, obtain repeat imaging

Clinically Stable

Defined as having all of the following:

  • Resp rate < 24
  • Heart rate 60-120 beats per minute
  • Normal BP
  • SaO2 >90% on room air and patient can speak in whole sentences

Workup
  • CXR
    • Displaced visceral pleural line without lung markings between pleural line and chest wall
    • Upright is best
      • Expiratory films DO NOT improve accuracy[1]
      • Lateral decubitus films with suspected side up do increase sensitivity. Good approach in pediatrics to avoid CT
    • Supine CXR = deep sulcus sign
  • CT Chest
    • Very sensitive and specific

Lung ultrasound of pneumothorax
  • No lung sliding seen (not specific for pneumothorax)
  • May also identify "lung point": distinct point where you no longer see lung sliding (pathognomonic)
  • Evaluate other intercostal spaces because pneumothorax may only be seen in least dependent area of thorax
    • NO comet tail artifact
    • Bar Code appearance/"Stratosphere" sign on M-mode (absence of "seashore" waves)

Estimating Pneumothorax Size
Measuring pneumothoraxes. Line A = lung apex to cupola. Line B = interpleural distance.
  • On a conventional, upright posterior-anterior chest radiograph:
    • Very small: <1 cm interpleural distance (confined to upper 1/3 of chest) OR only seen on CT
    • Small: ≤3cm lung apex to cupola (chest wall apex) on CXR
    • Large: >3cm lung apex to cupola (chest wall apex) on CXR
3cm apex to cupola measurement is roughly equivalent to 2cm interpleural distance (at the level of the hilum)
Both roughly correlate with a 50% pneumothorax by volume

Management

Supplemental oxygen with non-rebreather for all

Tension pneumothorax

Open pneumothorax
  • Cover wound with three-sided dressing
    • Make sure to avoid complete occlusion (may convert injury to a tension pneumothorax)

Closed traumatic pneumothorax
  • Tube thoracostomy indicated if:
    • Cannot be observed closely
    • Requires intubation
    • Will be transported by air or over a long distance
  • Observation if:
    • Very small AND does not require mechanical ventilation
    • Unchanged on repeat CXR in 6 hours
  • Decision to intubate
    • Intubation can lead to positive pressure which may worsen a stable traumatic pneumothorax
    • If patient stable, preferable to just perform thoracostomy
    • If GCS < 8 or patient having difficulty, they should be intubated

Adult Chest Tube Sizes
Chest Tube Size Type of Patient Underlying Causes
Small (8-14 Fr)
  • Alveolar-pleural fistulae (small air leak)
  • Iatrogenic air
Medium (20-28 Fr)
  • Bronchial-pleural fistulae (large air leak)
  • Malignant fluid
Large (36-40 Fr)
  • Traumatic pneumothorax
    • 2012 study using 28-32 Fr tube just as good as 36-40 Fr tube. [2] This is reflected in the ATLS 2019 Guidelines: "ATLS ® -10 now recommends placement of a smaller 28F to 32F chest tube for any acute hemothorax that is visible on chest radiograph." [3]
  • Empyema
  • Bleeding (Hemothorax/hemopneumothorax)
  • Thick pus

Disposition

Admit

Special Instructions

Flying

  • Can consider flying 2 weeks after full resolution of traumatic pneumothroax[4]

Complications

See Also

References
  1. Eur Respir J. 1996 Mar;9(3):406-9
  2. Inaba Et. al J Trauma Acute Care Surg. 2012 Feb;72(2):422-7.
  3. Advanced Trauma Life Support® Update 2019: Management and Applications for Adults and Special Populations.
  4. "Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010" British Thoracic Society Guidelines. Thorax 2010;65:ii18-ii31 doi:10.1136/thx.2010.136986 PDF
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