In a patient who has sustained blunt trauma who is found to have an occult pneumothorax on CT scan, is tube thoracostomy better than observation at reducing morbidity and mortality ? Presented by : Abdulgadir F. Bugdadi

Occult Pneumothorax A pneumothorax that is not suspected on the basis of clinical examination or plain radiography but is ultimately detected with thoraco-abdominal computed tomography.

OCCULT PNEUMOTHORAX IN BLUNT TRAUMA PATIENT: TUBE THORACOSTOMY OR OBSERVATION

Study type : Retrospective review. Publishement : Injury – SEPTEMBER – 2009.

Objectives Study conducted both to determine the incidence of OP and describe its current treatment status in blunt trauma population at a Canadian tertiary trauma center, Of interest were the rates of tube thoracostomy vs. observation without chest drainage and their respective outcome

Methods Data on all consecutive blunt trauma patients between October 1994 and March 2003 was reviewed. Outcome measures evaluated ; 1. Length of stay. 2. Discharge status (Dead vs. Alive). 3. Intervention and time of intervention (TT and its relation to PPV). Direct comparison bet. OP with TT group and OP without TT group… (in terms of baseline characteristics and outcome)

68 Occult pneumothoraces RESULTS 33 No TT (Observation) 35 Tube Thoracostomy 16 (48.4%)29 (82.8%)Positive pressure ventilation Similar Mean injury severity score (ISS) 10 days17.4 days Different Length of stay 9.1%11.4% Similar Mortality NoTension pneumothoraces

The natural hx. Of OPTX in blunt trauma pts. at our institution appears to be one of uneventful resolution irrespective of ISS, PPV, or placement of thoracostomy tube. The study suggest an interesting hypothesis that observation of the blunt trauma patients with OPTX without tube thoracostomy may be safe and contribute to a shorter hospital stay.

Recommendation These are observations that would benefit from further study in a large, prospective randomized controlled trial.

BLUNT TRAUMATIC OCCULT PNEUMOTHORAX: IS OBSERVATION SAFE?

Study type : Prospective, observational, multicenter study. Publishement : Journal of Trauma, infection and critical care – May

Objective To determine which factors predicted failed observation in blunt trauma patients

Methods Successfully observed patients and patients who failed observation were compared. 588 OPTX 121 (21%) immediate TT 448 (79%) observed

588 OPTX 121 (21%) immediate TT 448 (79%) observed 27 (6%) failed observation and required TT (1) Out of 73 pt. on PPV, 10 (14%) failed observation. Rest did not fail observation

Hospital and ICU lengths of stay, and ventilator days were longer in the failed observation group. OPTX progression and respiratory distress, significant predictors of failed observation. No patient who failed observation developed tension PTX, or experienced adverse events by delaying TT.

Conclusion Most blunt trauma pt. with OPTX can be carefully monitored without TT; however, OPTX progression and respiratory distress are independently associated with observation failure.

THE OPTICC TRIAL: A MULTI- INSTITUTIONAL STUDY OF OCCULT PNEUMOTHORACES IN CRITICAL CARE

Study type : Randomized trials. Publishement : American journal of surgery – 01 – may

objective To address the feasibility and safety of randomizing traumatized patients undergoing PPV to drainage or observation.

Methods Pts. randomized to observation (unless drainage became clinically indicated) or to chest tube. 24 trauma pts. enrolled (2 excluded b/c final CT; no OPTX). Episodes of respiratory distress (need for TT, acute/sustained increase in oxygen requirements, difficulty in achieving adequate ventilation and self reported distress) and subsequent imaging abnormalities were recorded until discharge.

DrainageObservation 9 (41%) pts.13 (59%) pts.Randomization All pts.4 pts. (31%) had CT placed non-urgently for worsening OPTX/effusion. None with increased morbidity Chest tube 33%41%Overall rates of respiratory distress 22%15%Overall mortality 1016In hospital days

Results and Conclusion Overall respiratory distress, mortality, in hospital days were similar across groups. With no important difference in morbidity, OPTICC trial lays the foundation for future trial comparing drainage or observation in post-traumatic OPTX requiring PPV.

OCCULT PNEUMOTHORAX IN CHINESE PATIENTS WITH SIGNIFICANT BLUNT CHEST TRAUMA: INCIDENCE AND MANAGEMENT

Study type : Prospective analysis of collected trauma registry. Publishement : Injury – 1- may – 2010.

Objective To identify the incidence of OP using TCT as the gold standard and describes its management amongst Hong Kong Chinese trauma patients.

Methods Analysis of prospectively collected trauma registry data. Consecutive significantly injured trauma patients admitted through ED suffering from blunt chest trauma who underwent TCT between calendar years 2007 and 2008 were included.

36 pts. With at least one OP. Bilateral OP in 8/36. Total no. were 44 8/44 had TT All were mechanically ventilated in ED 36 pts. Managed expectantly No pt. in the expectant group had pneumothorax progression (even though 8 pts. Required subsequent ventilation in the operating room for extrathoracic surgery)

Conclusion Most OP were managed expectantly without significant complications; no pneumothorax progressed even though some pts. Were mechanically ventilated. Incidence of OP in Chinese pt. after blunt trauma is higher than the typically reported in Caucasians.

MANAGEMENT OF TRAUMATIC OCCULT PNEUMOTHORAX

Study type : evidence based review Publishement : Resuscitation – 01 – September

Objective To evaluate existing evidence regarding the safety and efficacy of observation as compared to tube thoracostomy (TT) for management of OPTX in emergency department trauma patients

Methods Authors searched MEDLINE, EMBASE, the Cochrane Library, and other databases. Inclusion Criteria : studies of adult or pediatric trauma victims at first presentation after blunt or penetrating injury. Randomized to observation or TT. Studies that enrolled pts. On PPV were included. Excluded studies : studies that enrolled hemodynamically unstable patients.

Outcome of interest includes : progression of OPTX, mortality, complications (pneumonia, empyema), and length of stay in hospital and ICU. 411 articles identified. After application of inclusion and exclusion criteria, 3 randomized trials enrolling 101 patients were found to have acceptable quality standards suitable for analysis.

Results Inclusion studies did not reveal any significant difference between observation and TT in regards to progression of OPTX, risk of pneumonia, or length of stay in hospital or ICU.

Conclusion Existing evidence leads to the conclusion that observation is at least as safe and effective as tube thoracostomy for management of occult pneumothorax.

Answer According to previous studies it appears that Tube Thoracostomy is NOT BETTER than observation in reducing morbidity and mortality in a blunt trauma patient with occult pneumothorax.

END Thank You