Panamerican Journal of Trauma, Critical Care & Emergency Surgery

Register      Login

VOLUME 8 , ISSUE 1 ( January-April, 2019 ) > List of Articles

Original Article

Observing Pneumothoraces: The 35 Millimeter Rule is Safe in Ventilated Patients

Savo Bou Zein Eddine, Kelly A Boyle, Christopher M Dodgion, Christopher S Davis, Travis P Webb, Jeremy S Juern, David J Milia, Thomas W Carver, Marshall A Beckman, Colleen Trevino, Marc A de Moya

Keywords : Chest tube, Observation, Pneumothorax, Pneumothoraces, Trauma

Citation Information : Eddine SB, Boyle KA, Dodgion CM, Davis CS, Webb TP, Juern JS, Milia DJ, Carver TW, Beckman MA, Trevino C, de Moya MA. Observing Pneumothoraces: The 35 Millimeter Rule is Safe in Ventilated Patients. Panam J Trauma Crit Care Emerg Surg 2019; 8 (1):29-35.

DOI: 10.5005/jp-journals-10030-1234

License: CC BY-NC 4.0

Published Online: 01-04-2019

Copyright Statement:  Copyright © 2019; Jaypee Brothers Medical Publishers (P) Ltd.


Abstract

Background: Observing pneumothoraxes (PTXs) identified on chest computed tomography (CT) in mechanically ventilated patients remains highly debated. Despite the comorbidities associated with tube thoracotomy (TT), clinicians are inclined to perform this invasive procedure prophylactically. We hypothesize that PTX measuring ≤35 mm on chest CT can be safely observed in ventilated patients. Study design: A retrospective review was conducted of all patients diagnosed with PTX by chest CT between January 2011 and December 2016. Patients were excluded if they had an associated hemothorax (HTX), were not intubated, or had a TT placed before the initial chest CT. PTXs were measured as the radial distance between the parietal and the visceral pleura/mediastinum in a line perpendicular to the chest wall on axial imaging. Based on the previous work, a cutoff of 35 mm on the initial CT was used to dichotomize the groups. Failure of observation was defined as the need for a TT during the first week. A univariate analysis was performed to identify predictors of failure of observation in both groups. Results: A total of 116 patients met our inclusion criteria. Of those, 96 (83%) were successfully observed until discharge. Of those successfully observed, 88 (92%) patients had a measurement of ≤35 mm. In the univariate analyses, only the size of the PTX (≤35 mm or > 35 mm) (p = 0.001) was significantly associated with failing observation. The negative predictive value for 35 mm as a cutoff was 96.7% to predict successful observation. Conclusion: The 35 mm cutoff is safe as a general guide for ventilated patients with only 3% of stable patients failing initial observation.


PDF Share
  1. Omert L, Yeaney WW, et al. Efficacy of thoracic computerized tomography in blunt chest trauma. Am Surg 2001;67(7): 660–664.
  2. Brasel KJ, Stafford RE, et al. Treatment of occult pneumothoraces from blunt trauma. J Trauma 1999;46(6):987–990; discussion 990–991.
  3. Holmes JF, Brant WE, et al. Prevalence and importance of pneumothoraces visualized on abdominal computed tomographic scan in children with blunt trauma. J Trauma 2001;50(3): 516–520.
  4. Collins JC, Levine G, et al. Occult traumatic pneumothorax: immediate tube thoracostomy versus expectant management. Am Surg 1992;58(12):743–746.
  5. Zhang M, Teo LT, et al. Occult pneumothorax in blunt trauma: is there a need for tube thoracostomy? Eur J Trauma Emerg Surg 2016;42(6):785–790. DOI: 10.1007/s00068-016-0645-x.
  6. Moore FO, Goslar PW, et al. Blunt traumatic occult pneumothorax: is observation safe?–results of a prospective, AAST multicenter study. J Trauma 2011;70(5):1019–1023; discussion 1023–1025. DOI: 10.1097/TA.0b013e318213f727.
  7. Yadav K, Jalili M, et al. Management of traumatic occult pneumothorax. Resuscitation 2010;81(9):1063–1068. DOI: 10.1016/j.resuscitation.2010. 04.030.
  8. Ouellet JF, Trottier V, et al. The OPTICC trial: a multi-institutional study of occult pneumothoraces in critical care. Am J Surg 2009;197(5): 581–586. DOI: 10.1016/j.amjsurg.2008.12.007.
  9. Enderson BL, Abdalla R, et al. Tube thoracostomy for occult pneumothorax: a prospective randomized study of its use. J Trauma 1993;35(5):726–729; discussion 729–730.
  10. Cropano TMC, Turay D, et al. Pneumothoraces on Computed Topography Scan: Observation using the 35 Millimeter Rule is Safe. Panam J Trauma Crit Care Emerg Surg 2015;4(2):48–53.
  11. de Moya MA, Seaver C, et al. Occult pneumothorax in trauma patients: development of an objective scoring system. J Trauma 2007;63(1):13–17. DOI: 10.1097/TA.0b013e31806864fc.
  12. Kirkpatrick AW, Rizoli S, et al. Canadian Trauma Trials Collaborative and the Research Committee of the Trauma Association of Canada. Occult pneumothoraces in critical care: a prospective multicenter randomized controlled trial of pleural drainage for mechanically ventilated trauma patients with occult pneumothoraces. J Trauma Acute Care Surg 2013;74(3):747–754; discussion 754–755. DOI: 10.1097/TA.0b013e3182827158.
  13. Park HO, Kang DH, et al. Risk factors for pneumonia in ventilated trauma patients with multiple rib fractures. Korean J Thorac Cardiovasc Surg 2017;50(5):346–354. DOI: 10.5090/kjtcs.2017.50.5.346.
  14. Walker SP, Barratt SL, et al. Conservative management in traumatic pneumothoraces: an observational study. Chest 2018;153(4): 946–953. DOI: 10.1016/j.chest.2017.10.015.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.