Pneumothorax

Traumatic pneumothoraces are common with both blunt and penetrating mechanisms, and can be caused by direct penetration of a missile or other object through the chest wall, a closed laceration of the lung parenchyma from a fractured rib, or a sudden increase in intrathoracic pressure. During the initial assessment, clinical evidence of a tension pneumothorax calls for immediate needle decompression or tube thoracostomy of the pleural space involved. However, most pneumothoraces are diagnosed by chest radiography.

In most cases, traumatic pneumothoraces are treated with tube thoracostomy. A posterior chest tube is usually placed because an associated hemothorax is common, even if it is not obvious on the initial chest radiograph. Under selected circumstances, patients with small pneumothoraces may be observed. This mandates careful re-examination and repeat chest radiography to ensure that there is no progression of the pneumothorax. Small pneumothoraces which are not evident on the initial chest radiograph may be identified in trauma patients undergoing chest or abdominal CT scans. In general, most of these 'occult pneumothoraces' can be safely observed according to these same principles. However, observation is not recommended for patients with small or occult pneumothoraces who are on positive-pressure ventilation or who will need to undergo operative procedures under general anesthesia.

Once a chest tube has been inserted, it is placed on suction. A follow-up chest radiograph is obtained to ensure that the lung has been fully re-expanded. If there is no evidence of an air leak, the tube can usually be removed after 48 to 72 h. Some clinicians prefer to leave the chest tube on water seal for 6 to 24 h prior to removal to ensure that a recurrent pneumothorax will not develop. In any case, a follow-up chest radiograph should be taken following the removal of the chest tube to ensure that a pneumothorax has not redeveloped.

If the patient has a continued air leak, a repeat chest radiograph should be checked for a persistent pneumothorax. If this is found, an additional chest tube is placed, usually directed anteriorly and superiorly. Nearly all air leaks will eventually seal if the lung is fully re-expanded and the chest tube is kept on suction. Generally, an air leak must persist for at least 14 days before operative intervention is considered. The primary exception to this rule is the patient with a major bronchial injury, which is suggested by a very large air leak and an inability to re-expand the lung with closed-tube thoracostomy.

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