the occult pneumothorax - (opticc) occult pneumothorax in

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  • The Occult Pneumothorax: Issue or Incidental?AW Kirkpatrick CD MD FRCSCRegional Medical Director of Trauma, The Region Formerly known as Calgary

  • Learning ObjectivesDefine what is meant by the term occult pneumothoraxDefine the epidemiology of occult pneumothoracesDefine the diagnostic strategies to detect occult pneumothoracesDefine the controversies in the occult pneumothorax managementDefine the risks involved in either treating or observing occult pneumothoraces

  • The MessagePneumothoraces (PTXs) in 1/5 victims of major blunt trauma found aliveNot treating tension PTXs is a leading cause of preventable deathCXR misses at least half of all PTXs seen on CT scan (at FMC)- called OPTXsWe dont really know what to doCurrently no organized approach and the current treatments are widely divergentIatrogenic harm does rise in RxWe hope to learn more in the future through the occult pneumothorax trial hopefully in your hospital

  • AW Kirkpatrick DisclosureI do not have an affiliation (financial or otherwise) with any commercial organization that may have a direct or indirect connection to the content of my presentationI have received unrestricted research funding to investigate the relevance of occult pneumothoraces from the;David Thompson Award of the Canadian Intensive Care Foundation (CICF)Canadian Trauma Trials Collaborative (CTTC) of the Trauma Association of Canada

  • A Case25 year old female in a small car rollover MVCClosed head injuryGrade II splenic laceration treated non-operativelyOpen fumur fracture treated with an IM nailIndistinct mediastinal contour

  • CXR

  • Learning Objective 1Define the term Occult PneumothoraxA PTX identified on an abdominal CT scan that was not seen on a preceding supine AP CXR1Wall SD, Am J Radiol 1983

  • Rationale Thoracic TraumaResponsible for 25% of all trauma deathsPneumothoraces are the most common serious intra-thoracic injury following blunt trauma1,21/5 incidence in victims of major trauma found alive31ATLS Course, 2Richardson 19963Di Bartolemeo, J Trauma 2001

  • Management?

  • ATLS Recommendations2008 Recommendations

  • Alternate OpinionsA subset of patients with blunt OPTXs requiring positive pressure ventilation may be safely managed without tube thoracostomy.16/20 vented patients avoided a chest tubeBarrios et al, Am Surg 2008

  • Debate

  • Second Opinions from other Trauma Surgeons

  • Multi-Disciplinary Decision MakingMedical, Nursing, Respiratory Therapy

  • Anaesthesia Consultation

  • Internal Medicine Consultation

  • Back to the Books Literature Search

    PubMed literature search for previous randomized controlled trials on the occult pneumothorax

  • PubMed Search: Occult Pneumothorax AND Mechanical Ventilation LIMITED TO RCTs1 single study!!!Enderson BL, Abdalla R, Frame SB, Casey MT, Gould H, Maull KI. Tube thoracostomy for occult pneumothorax: a prospective randomized study of its use. J Trauma. 1993 Nov; 35(5): 726-9; discussion 729-30. PMID: 8230337 [PubMed - indexed for MEDLINE]

  • Related ArticlesReveals a second studyBrasel KJ, Stafford RE, Weigelt JA, Tenquist JE, Borgstrom DC. Treatment of occult pneumothoraces from blunt trauma. J Trauma. 1999 Jun; 46(6): 987-90; discussion 990-1. PMID: 10372613 [PubMed - indexed for MEDLINE]

  • Results (Enderson 1993)3261 trauma patients admitted over 18 months709 (21.7%) had abdominal CT scanning40 (5.6%) had OPTXs 21 randomized to observation19 randomized to chest tubeUniversity of Tennessee, Knoxville, TN

  • Demographics

  • Only 27 patients ventilated

  • Positive Pressure Ventilation15 ventilated with a chest tube12 ventilated without a chest tube

  • Complications - EndersonSignificantly more major complications in the observed group (p
  • Conclusions Enderson 1993Patients with occult PTXs who require positive pressure ventilation should undergo tube thoracostomy

  • Brasel 1999OPTXs defined as PTXs not seen on supine CXRs but seen on helical ABDOMINAL CT scan39 patients with 44 OPTXs enrolledRandomized (bilateral PTXs randomized by patient)18 chest tubes21 observedSt. Paul-Ramsey Medical CenterSt Johns Regional Health Center

  • Results (Brasel 1999)5126 trauma patients admitted over 18 months(1669) had abdominal CT scanning86 (5.2%) patients had OPTXsNot 5.9% as reported math!39 (45%) enrolled21 randomized to observation (24 PTXs)18 randomized to chest tube (20 chest tube)Demographics comparable - table

  • Demographics

  • Mechanical Ventilation9 each group required ventilation3 each group only for operative proceduresSix each group longer than 24 hours ventilationNo difference in ventilation days

  • Outcomes in the Mechanical Ventilation Group Brasel 1999 No patient had respiratory distress related to an occult PTX or required emergent tube thoracostomy Chest tube placedNo emergent chest4 had PTX progression related to coming off suction

    Observed with no chest tube3 had PTX progression2 on PPV had chest tubes placed (33% of this group)Chest tubes also placed forRetained hemothoraxIncreased pleural effusionAsymptomatic PTX progressionSpinal surgery

  • Conclusions Brasel 1999Possible to safely observe patients regardless of the need for PPV or PTX size!!

  • The (conflicting) World Literature2 small studies with only 45 patients are the cumulative world experience for those randomized to clinical trial experienceDiametrically opposed results

  • Building the CaseLiterature Review Can J Surg (2003) + (in press)Epidemiology and Incidence (J Trauma 2005)Anatomic Distribution (Am J Surg 2005)Diagnostic Errors (J Trauma 2006)Complications (Can J Surg 2007)Randomized Pilot Data to Power the Definitive Trial (Am J Surg 2009)

  • Literature ReviewBall CG et al., The Occult Pneumothorax: What Have we Learned from the Recent Literature? Can J Surg (in press) 2009

  • Incidence

  • How Common Are They?Incidence among all trauma patients: 1- 64%Most approximate: 5-8% of patients with CTUp to 72% of all PTXs are first detected on CTMajority are greater than 50% occultFrequency depends on:Extent of CT imagingInjury SeveritySelected CohortIncreasingly common with accelerating CT use

    Ball CG, Kirkpatrick et al., Occult pneumothorax in the mechanically ventilatedtrauma patient, Canadian Journal of Surgery, 2003.

  • Management (including retrospective)

  • OPTX ImagingSupine AP chest radiograph is the initial imaging test in most trauma patientsLeast sensitive of all plain radiograph techniques for diagnosing pneumothoraces (up to 400cc)Images are more difficult to interpretPneumothoraces do not appear in classic locationsCXR is inaccurate in defining size and location of a pneumothoraxTrupka A et al. 1997 ; Cooke DA 1987 & Chan SS 2003

  • Occult PneumothoraxA PTX identified on an abdominal CT scan that was not seen on a preceding supine AP CXR

  • Diagnostic Ultrasound &Occult PneumothoracesLichtenstein 2005357 hemithoracesSens-95%, spec 94%Blaivas 2005176 patientsSens 98.1%, spec 99.2%

  • Needle Decompression of a tension pneumothoraxKirkpatrick et al., J Trauma 2009

  • Lung Sliding = Hearing Breathe Sounds

  • With Pneumothorax the Normal Signs are Gone

  • Lung Point SignReproduced with permissionLichtenstein, Critical Care Medicine 2005;33:1231-1238

  • The Calgary Experience:How Common Are They?Trauma Registry studyOPTX incidence = 15% of all seriously injured patients with a thoracoabdominal CT scanOPTX incidence = 6.1% of all registry patients55% of all pneumothoraces were occult to supine AP CXRBall CG, Kirkpatrick et al., Incidence, risk factors and outcomes for occultpneumothoraces in victims of major trauma, Journal of Trauma, 2005.

  • PTX prospective incidence = 26% of 405 patients receiving a thoracoabdominal CT had a PTX76% of these were considered occult by the treating physicians

    The Prospective Calgary Experience 4 yrs laterBall CG, et al., Clinical predictors, Injury 2009

  • Where are they anatomically?

  • PTX DistributionOccult OvertResidualApical21 (57%)7 (58%)11 (42%)

    Basal15 (41%)7 (58%)16 (62%)

    Lateral9 (24%)7 (58%)10 (38%)

    Medial10 (27%)6 (50%)8 (31%)

    Anterior31 (84%)9 (75%)23 (88%)

    Posterior01 (8%)1 (4%)

    Apical Only6 (16%)3 (25%)N/A

    Ball CG, et al., American Journal of Surgery, 2005.

  • PTX Size89 PTXs13 overt49 OPTX27 residualBall CG, Kirkpatrick et al., J Trauma 2005;59:917-925

  • Why Do We Miss Them? Group 1Group 2Group 3Sensitivity21%23%9%Specificity100%89%89%PPV100%91%80%NPV21%19%17%Ball, J Trauma 2006

  • Potential plain radiographic signs of an occult PTXDouble diaphragmDeep sulcusHyperlucent hemithoraxSharpened cardiac silhouetteDepressed diaphragmApical pericardial fat sign

  • Why Do We Miss Them?Group 1Group 2Group 3Deep Sulcus7(78%)9(90%)3(75%)Crisp Cardiac1(11%)1(10%)0Pleural Line1(11%)01(25%)Total Dx9(21%)10(23%)4(9%)Ball CG, Kirkpatrick et al., Are occult pneumothoraces truly occultor simply missed?, J Trauma 2006.

  • How Should They Be Managed?OPTXVentilatedNon-VentilatedTotal (N)17 (35%)32 (65%)Median ISS34*22.5*

    Received TT13 (76%)10 (31%)Required TT1 / 4 (25%)1 / 22 (5%)After PTX ProgressionBall CG, J Trauma 2005

  • Complications of chest tubesUp to 30% of chest tubesVascular InjuryPainImproper positioningInadvertent tube removalPost-removal complicationsLonger hospital staysEmpyemaPneumoniaEtoch Arch Surg 1995, Bailey J Accid Emerg Med 2000

  • Chest Tube Complica

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