THE OCCULT PNEUMOTHORAX (OPTX)
Abstract:
The management of pneumothorax detected on CT but not on chest radiography remains controversial. Of 456 patients with multisystem injuries undergoing abdominal computer tomography (CT) scan, 25 patients were found to have 30 pneumothoraces and none of these were apparent on prior roentgenograms of the chest. The management of pneumothoraces detected on CT remains controversial especially in those undergoing positive pressure ventilation (PPV) who are at risk for complications regarding both observation and treatment. In this category, 24 trauma patients were enrolled. From these 24 patients, 59% were randomized to observation, 9 were submitted to drainage (41%). Overall rates of respiratory distress and mortality were similar regarding the groups of PPV patients. The determining major factor in the clinical evolution and management of these pneumothoraces was the size. Each pneumothorax was quantified by measuring its maximal width in millimetres with CT sections. Serial roentgenograms of the chest were reviewed. In the pneumothorax measuring 5*80 mm (group 1), positive pressure ventilation was of 55% and in > 5*80 mm (group 2), positive pressure ventilation was of 77%. 17% from group 1 and 85 % from group 2 had tube thoracostomy. Our results suggest that such occult pneumothoraces may be managed with close observation if they measure <5*80 mm, whether or not the patient is to receive positive pressure ventilation. Larger pneumothoraces and pneumothoraces associated with more than two rib fractures may require early treatment. All patients benefit from expiration posteroanterior chest radiograph and should be re-evaluated 24,48 hours later and on days: 7,14,21. A safe algorithm is recommended: expiration chest radiography for every patient who suffered blunt thoracic injury with at least one rib fracture detected. Close follow-up is also suggested since these entities do exist or when they cannot be ignored and their treatment suggests the early evacuation of the pleura cavity.
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