Abstract

The clinical presentation of pneumothorax ranges from no symptoms to life-threatening tension physiology requiring emergent intervention. The thoracic cavity is lined with parietal while the lungs and mediastinal structures are lined with visceral pleura. Normally in apposition, a potential space exists between these two layers where fluid, air, or a combination of the two may accumulate. If this potential space fills with fluid or air, subsequent collapse of the lung tissue causes symptoms such as shortness of breath and tachypnea. If the fluid or air accumulate to the degree that venous cardiac return is impeded, tension physiology ensues with hypotension, tachycardia, and eventual cardiovascular collapse if the pressure is not relieved. Tube thoracostomy remains the treatment of choice for managing pneumothorax. Here, we present the management of a traumatic pneumothorax with tube thoracostomy in a 51-year-old male injured in a motor vehicle collision.

Background

Chest trauma is the third most common injury secondary to a motor vehicle accident, behind head and extremity trauma.¹ Traumatic pneumothorax is classified as either penetrating or non-penetrating depending on the mechanism of injury. The pathophysiology of a penetrating pneumothorax involves a wound allowing air to enter the pleural space directly through the chest wall. In a non-penetrating pneumothorax, the visceral pleura may be lacerated due to rib fractures or violated from a high degree of blunt force to the thorax with no associated fractures. In both cases, air enters the pleural space, disrupting the tight apposition between the visceral and parietal pleura.

Chest tubes are utilized to remove fluid and air from the pleural space in the event of effusion or pneumothorax. The oldest known reference to thoracic drainage dates back to the fifth century BCE with Hippocrates.² Techniques from the mid-19th century Napoleonic Wars consisted of rubber tubes and syringes that resulted in increased survival of the patient.³ Although thoracic drainage has existed for thousands of years, tube thoracostomy is more recent and dates back to World War II. Early difficulties resulted in a high complication rate due to a lack of experience and equipment deficiencies. As technology improved and practitioners became more comfortable performing the procedure, the success rate of tube thoracostomy increased and became the standard of care in the treatment of pneumothorax.⁴

In the case presented here, the patient suffered a moderate-sized hemopneumothorax due to chest wall trauma suffered from a motor vehicle accident. A chest tube was placed between the 4th and 5th ribs to remove blood and air from the pleural space.

Focused History of the Patient

A 51-year-old male patient presented to the University of Chicago Emergency Department following a motor vehicle accident that occurred 8 hours prior to arrival. The patient was not initially triaged to the Trauma Unit as he was not taken to the hospital immediately following the accident. He decided to seek medical care after experiencing persistent left-sided chest wall pain while at home. The Emergency Department team obtained a chest X-ray and a Chest CT. This imaging demonstrated a moderate-sized left hemopneumothorax. Following these findings the patient was re-located to the Trauma Unit where the patient was definitively managed with left tube thoracostomy.

Physical Exam

The physical exam findings consistent with a traumatic pneumothorax include chest pain, dyspnea, and tachypnea.² Other common physical exam findings consistent with a traumatic pneumothorax include hyperresonance to percussion and diminished breath sounds upon auscultation.² Late findings of tension physiology secondary to decreased venous return include distended neck veins, hypotension, and tachycardia.⁵

Imaging

Chest radiograph is the initial imaging modality of choice for detecting pneumomothorax. Chest CT may be used adjunctively, but in the traumatic setting, tube thoracostomy is indicated for a pneumothorax detected on physical exam or chest radiograph. If a pneumothorax is clinically suspected in a patient with recent traumatic injury, definitive treatment with tube thoracostomy should not be delayed for imaging confirmation. In the case presented here, both chest radiograph and chest CT were obtained prior to the consultation of the Trauma service.

Natural History

The natural history of a traumatic pneumothorax differs based on individual patient factors, injury pattern, and severity of injury. If left untreated, the interplay of these factors will ultimately determine whether a pneumothorax will be resorbed, remain stable in size, or expand with the potential to cause tension physiology.

Options for the Treatment

Evaluation should begin with an assessment of the primary trauma survey-systematically evaluating airway patency, respiratory function, and hemodynamic function. Tube thoracostomy is the primary treatment modality for pneumothorax and should not be delayed when diagnosed following trauma in the hospital setting. An active topic of research in the trauma literature over the last two decades has been investigation into which pneumothoraces may be safely observed without chest tube placement. Certain tiny pneumothoraces may be observed safely without tube thoracostomy, but the criteria for selecting these patients, the requirements for follow-up imaging, and observation requirements for these patients is beyond the scope of discussion here.

Complications of tube thoracostomy include bleeding (including injury to the intercostal neurovascular bundle along the underside of each rib), infection, and lung injury.² Tube thoracostomy should be completed as a sterile procedure except in case of life-threatening urgency where hemodynamic collapse is imminent.

Rationale for the Treatment

In this clinical scenario, the patient presented with a hemopneumothorax as air and blood had accumulated in the pleural space. Tube thoracostomy was utilized to drain the air and blood by positioning the chest tube in the posterior and basilar position where blood was most expected to accumulate. When a hemothorax is present, the ability to adequately drain accumulated blood is a key factor in minimizing the dreaded sequelae of retained hemothorax and subsequent infection.

Procedure

Before the procedure was performed, patient identity was confirmed and the side of the planned procedure was confirmed. During the timeout process, the patient received 2 g Ancef for infection prophylaxis. The patient was prepped before draping and was also connected to continuous pulse oximetry for continuous monitoring of vital signs. Pain management included injections of 1% lidocaine for local anesthesia. Intravenous fentanyl and ketamine were immediately available if additional analgesia was required. Placement was directed toward the 4th–5th intercostal space along the midaxillary line, corresponding to the level of the nipple. Lidocaine was administered into the superficial skin, into the periosteum of the rib, and a small amount in the pleural space. The key steps include an initial incision, the usage of Kelly forceps to produce a subcutaneous tunnel, and careful placement of the chest tube immediately above the inferior rib to avoid neurovascular bundle injury (which runs on the underside of the superior rib). Once anesthesia was adequate and the preparation of the tube and Pleur-evac was completed, the procedure was started. After the incision, a tunnel was made onto the rib. Next, the tube was placed and unclamped, allowing for the expulsion of air and blood. The first stitch placed was to secure the chest tube to the chest wall. The second stitch placed was a U-stitch which would be used to close the incision site at the time of chest tube removal. An additional interrupted suture was placed to close the skin tightly around the chest tube. An air-tight dressing was applied around the chest tube and over the incision site. At the completion of the procedure, a chest X-ray was performed to confirm the location of the tube and to ensure improvement in appearance of the pneumothorax. The posterior and basilar position was confirmed by the X-ray. An additional X-ray was obtained the following morning.

Discussion

In the case presented above, although the patient’s hemopneumothorax was successfully treated with chest tube thoracostomy, alternatives have been utilized amongst surgeons.

Although the absence of respiratory sounds and the presence of subcutaneous emphysema exists in up to 100% of tension pneumothoraces, some might not present with such defining features on imaging and go unnoticed on chest x-ray.⁶ This subtype of pneumothorax occurs in 2-20% of blunt chest trauma patients and is termed an occult pneumothorax. Occult pneumothoraces can be detected on CT and ultrasound, which can have a sensitivity of up to 98.1%.⁶ Urgent evaluation is necessary in such patients as these occur in 51% of trauma patients with a pneumothorax with possible progression to a tension pneumothorax6. For those with subcutaneous emphysema, fractured ribs, or a pulmonary contusion, the clinical suspicion for an occult pneumothorax should be high and thus evaluated with a chest CT. Gaining more recognition in the medical community is the use of ultrasound in patients with multiple injuries requiring spinal immobilization. The advantage to using ultrasound is the lack of invasiveness and the avoidance of radiation exposure. For those with occult pneumothoraces, the general approach should be continuous monitoring of vital signs as long as the patient is stable and without symptoms.⁶

In those with extensive trauma, the use of a CT in severe shock patients can be difficult. In those with multiple fractures and no experienced ultrasound user nearby, it’s been proposed that the use of an oblique chest x-ray can be used in these situations.⁷ One author reported a sensitivity, specificity, and accuracy of an oblique chest x-ray to be 61.4%, 99.2%, and 90.9%, respectively which is very comparable to the statistics seen with a thoracic ultrasound.⁷

The use of percutaneous pleural pigtails have been mentioned in literature for the treatment of traumatic blunt injury to the chest. In one study, pigtail catheters were mentioned as an emerging technique that is effective and less morbid than its counterpart, a large bore chest tube.⁸ Advantages to using the pigtail catheter is its smaller caliber size and increased flexibility. This results in less pain being produced and less injury to nearby tissue.⁸ Some complications that may arise is kinking of the catheter due to its smaller diameter, air emboli, subclavian vein laceration, inadvertent placement of catheter in left ventricle which occurred in one rare case with a 3 year old, and rarely lung parenchyma penetration.⁸ In another study for the treatment of a traumatic hemothorax/ hemopneumothorax, the authors found no difference between the draining capabilities of a pleural pigtail compared to a chest tube.⁹ In addition, patients found that the use of a pleural pigtail was associated with a better experience with less pain compared to a chest tube. Baseline characteristics of the patients, failure rates, and duration of tube insertion were similar between the cohorts.

One additional alternative to using a chest tube is the utilization of a thoracic vent.¹⁰This small sized portable pneumothorax kit is a minimally invasive kit that can be used for emergency situations. An advantage to this technique compared to a chest tube is allowing the patient to be treated on an outpatient basis with increased mobilization, which reduces overall medical costs. One study with 18 patients had no complications from the procedure and had a clinical success rate of 88.9%, which was defined as complete resolution of signs and symptoms related to the pneumothorax.¹⁰ Furthermore, at the 3 year follow up recurrence-free overall success rate was 72.2%. In another study comparing it to an intercostal chest tube, they recommended the use of a thoracic vent as first line therapy.¹¹

Although the tradition is to use a chest tube for the treatment of a pneumothorax, many techniques are used in alternatives when certain situations arise. This article describes the use of a chest tube thoracostomy and describes the alternatives with their potential benefits.

Equipment

Chest tube
Scalpel
Hemostat
O-silk stitches
Pleur-evac® Chest Drainage System

Disclosures

Nothing to disclose.

Statement of Consent

The patient referred to in this video has given their informed consent to be filmed and is aware that information and images will be published online.