Management of pneumothoraces detected on chest computed tomography: can anatomical location identify patients who can be managed expectantly?

Background: Pneumothorax (PTX) can be readily detected by computed tomography (CT) or ultrasound. However, management of PTX in hemodynamically stable patients remains controversial.

Study Objectives: We sought to investigate whether a distinct anatomical distribution of PTX along prespecified chest zones as detected by CT can be described in patients with or without subsequent chest tube thoracotomy (CTT), thus potentially allowing the extended focused assessment with sonography for trauma (EFAST) ultrasound examination to guide PTX management.

Methods: We performed a retrospective review of chest CT scans performed in the emergency department (ED) of a Level I trauma center. CT scans were analyzed for PTX distribution according to a chest zone model. Medical records of subjects with PTX were reviewed for subsequent CTT.

Results: Of 3636 chest CT scans performed, 183 PTX (156 patients) were detected without CTT at the time of CT scan (69% male, mean age 42 years). Of these, 66 subjects (40%) underwent CTT; 43 chest tubes (63%) were placed in the ED, 9 (13%) during hospitalization and 9 (13%) in the operating room. Median time to CTT was 140 min (interquartile range 52-199). Initial hemodynamic parameters, need for surgery, and need for mechanical ventilation were similar in both groups (p > 0.05 for all). Anatomical distribution and size of PTX were similar in the two groups.

Conclusion: Although the majority of patients with traumatic PTX could be managed conservatively, we did not identify a characteristic anatomical PTX pattern, which could identify subjects who may not require CTT.