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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
[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.

Search Outcome

A total of 524 unique papers was identified from Medline and from Embase of which three were relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
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 Majority of patients with penetrating wounds may not be reflective of other populations
			Clinical deterioration	No clinical deterioration in group treated expectantly
Johnson G May 1996 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
Obeid FN, Shapiro MJ, Richardson HH, Horst HM, Bivins BA Sep 1985 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

Comment(s)

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.

Clinical 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

1. Knottenbelt JD, van der Spuy JW. Traumatic Pneumothorax:a scheme for rapid patient turnover. Injury 1990;21:77-80.
2. Johnson G. Traumatic pneumothorax: is a chest drain always necessary? Journal of Accident and Emergency Medicine May 1996;13(3):173-4.
3. Obeid FN, Shapiro MJ, Richardson HH, Horst HM, Bivins BA. Catheter Aspiration for Simple Pneumothorax (CASP) in the Outpatient Management of Simple Traumatic Pneumothorax. The Journal of Trauma Sep 1985; 25(9):882-886.