U N I V E R S I T Ä T S M E D I Z I N B E R L I NU N I V E R S I T Ä T S M E D I Z I N B E R L I N

Tobias Lindner

Emergency Dpt.- Trauma Wing

Pneu Concepts in Pneumothorax

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Diagnostics ….. WHAT DO WE HAVE ?

clinicial examination chest film ultrasound CT

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Diagnostics …..clinical examination auscultation alone is not reliable !

118 patients, penetrating chest injury

71 (60%) with Ptx

30 of these (42%) not diagnosed by inhospital auscultation !

(control: chest radiograph !) Chen et al. : Hemopneumothorax missed by auscultation in

penetrating chest injury. J Trauma. 1997

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Diagnostics ….. chest film……

….. there is a problem: occult pneumothorax

109 patients after chest trauma

only 13 of 25 PTXs detected by

supine ap chest film (control: CT)

sensitivity 52%, specifity 100 %

Soldati et al. : Occult traumatic pneumothorax: diagnostic accuracy of lung ultrasonography in the emergency department. Chest. 2008

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blunt chest trauma, cyclist hit by car

Diagnostics ….. chest film……

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blunt chest trauma, pedestrian hit by metal from lorry

Diagnostics ….. chest film……

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Diagnostics ….. ultrasound…….

Ouellet J-F et al., The sonographic diagnosis of pneumothorax. J

Emerg Trauma Shock. 2011Stone MB et al., The heart point sign: description of a new ultrasound finding suggesting pneumothorax.Acad Emerg Med. 2010

seahore- sign

stratosphere- sign

M- mode, sliding lung sign

comet- trail- artifacts

reverberations

B- mode

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M- and B- mode, 3 min. per side, convex probe

operators at least 1 year experience (ER personnel)

23 of 25 PTXs detected by ultrasound (remember: only 13 by ap chest film !)

92 % sensitivity, 99.4 % specifity, NPV 98,9

Soldati et al. , Occult traumatic pneumothorax: diagnostic accuracy of lung ultrasonography in the emergency department. Chest. 2008

Diagnostics ….. ultrasound…….

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evidence based review (chest ap radiograph vs US)

4 prospective studies, gold standard: CT

606 patients, blunt trauma cases

US: sensitivity 86- 98 %, specifity 97- 100 %

chest ap supine: sensitivity 28-75 %, specifity 100 %

RG Wilkerson et al., Sensitivity of Bedside Ultrasound and Supine Anteroposterior Chest Radiographs for the Identification of Pneumothorax After Blunt Trauma. Acad Emerg Med.. 2010

Diagnostics ….. ultrasound……

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20 studies, US: pooled sensitivity/ specifity = 88/ 99 % (CR: pooled sensitivity/ specifity = 52/ 100 %) bedside US performed by clinicians had higher

sensitivity and similar specificity compared to CR US depended on the skill of the operators US is reliable & advantage of portability, rapidity and

non biological invasive

Diagnostics ….. ultrasound……

Ding et al., CHEST. 2011

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however……….

does not favor ultrasound in diagnosing spontaneous PTX – results too conflicting

(for them !)

Diagnostics …..

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......instead: standard erect chest x- ray in inspiration (SP)

lateral views might be helpful, but no routine

expiratory films without additional benefit

in doubt : CT

Diagnostics …..

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Therapy…..Guidelines ?

Primary & Secondary Spontaneous Pneumothorax

(PSP/SSP)

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2001

2010

&

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Therapy……PSP (small, stable)

small* vs large stable** vs unstable

*apex/ cupula distance < 3cm on chest film**resp. rate < 24/ min., hr

> 60/ min. and < 120 /min., bp normal, O2 sat. room air > 92 %

small* vs large clinical compromise breathlessness ? **

*hilum to lateral chest wall < 2 cm on chest film

**not definded

observation in ER for 3-6 hrs.check x- rayDISCHARGE (if unchanged)

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Therapy…..PSP (large, stable/unstable)

stable & large: small- bore catheter

(< 14 F) or chest tube (16-22F)

discharge possible with Heimlich valve

unstable & large: small- bore catheter

or chest tube admit !

>2cm &/or breathless: needle aspiration discharge after check x- ray

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stable, small: observation or tube fatal cases during

observation reported !!! (O´Rourke. Chest. 1989)

all others: chest tube

admit all !

Therapy…….SSP

only in < 1 cm without compr.:

consider observation or NA size 1-2 cm/ not

breathless: needle aspiration

2cm at level of hilum &/or breathless: small bore catheter

admit all !

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(needle aspiration) small- bore catheter (<

14F) chest tube (16- 28F)

needle aspiration 1st choice, unless:

bilateral PTX SSP and > 2cm at level of hilum on CR

small bore chest drains (8-14F) (generally, no need for larger bore catheters in all spontaneous PTX)

2001

2010

Bringing it together……

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NA vs Chest tube in PSP 1 included study, total of 60 patients 27 underwent simple aspiration 33 underwent intercostal tube drainage

no significant difference with regard to: immediate, one week or one year success rate

simple aspiration is associated with a reduction in hospitalization rate (53 vs 100 %)

Wakai et al., Simple aspiration versus intercostal tube drainage forprimary spontaneous pneumothorax in adults. Cochrane review.

2007.Based on: Noppen 2002

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review NA as safe and successful as tube thoracostomy fewer hospital admissions after NA shorter hospital stays (if admitted)

Zehtabchi et al., Management of Emergency Medicine Department Patients

With Primary Spontaneous Pneumothorax : Needle Apsiration or TubeThoracostomy ? Ann of Emerg. Med.. 2008.

review NA might fail in larger PTX also SSP studies included !

Chan et al. , The Role of Simple Aspiration in the Management of Primary

Spontaneous Pneumothorax, J of Emerg. Med., 2008.

NA vs Chest tube in PSP

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general remarks: supplementary O2 therapy (at least 24 h)

- increases resolution rate by reduction of nitrogen partial pressure

no flights until then plus 1 week, but:generally, recurrence risk drops sign. only after 1 year !

no diving unless bilateral pleurodesis !

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chest drain removal:

41 % of panel members do clamp all check CR before removal 63 % after 13-23hrs after last evidence

of air leak

clamping is generally unnecessary period without suction before

removal

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Traumatic PTX

general remarks:

2nd rank of injury after chest trauma (after rib fx)

relevant prehospital Dx !

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Diagnostics …..clinical examination

might be (more) reliable in trauma than in spontaneous Ptx

!

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Traumatic PTX- Diagnostics

synopsis of auscultation, respiratory rate /shortness of breath. diagnostic accuracy can be improved by combining these three signs…… (and putting hands on ! )

Waydhas et al.,Prehospital pleural decompression andchest tube placement after blunt trauma: A systematic review.Resuscitation. 2007.

……..but still: clinical examination is very variable…..

……. need of: safe, objective method independent from setting

German Guideline on Polytraumamanagement- Prehospital Section, 2010

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Diagnostics ….. ultrasound……

prehospital: possible as on scene method

but still

skill dependend !

Kirkpatrick et al. , Hand- Held Thoracic Sonography for Detecting Post- Traumatic Pneumothoraces: The Extended Focused Assessment With Sonography for Trauma. J of Trauma. 2004

Walcher et al., Optimierung desTraumamanagements durch präklinische Sonographie. Unfallchirurg. 2002

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Diagnostics …..what else is on the horizon ?

micropower impulsed radar/ultrashort radar pulse

spatial accuracy of approx. 5mm

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Diagnostics …..what else is on the horizon ?

portable/ point of care non- invasive easy 1-2 min. scan time skin contact unnecessary penetrate through clothing ? specific location and volume ?

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Diagnostics …..what else is on the horizon ?

promising !

easy, quick, repeatable, not this operator depended, objective !

INDEPENDENT from preclinical setting !

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Therapy –Traumatic PTX

should all be treated with chest drains !

air & blood ! 28- 36 F !

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Pneu Concepts in Pneumothorax

US is accepted (in experienced operators hands) for diagnosing PTX

needle aspiration is the evolving method of choice for active intervention in MOST spontaneous PTx !?

there is an urgent need for a easy & objective tool for PTX diagnostics in the prehospital setting !

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Danke !