A critical appraisal on whether a traumatic pneumothorax should be managed conservatively
Aims
Discuss when it is appropriate to use conservative management for a traumatic pneumothorax.
Highlight the complications associated with conservative management.
Discuss when it is appropriate to intervene with a tube thoracostomy.
Highlight the complications associated with the use of a tube thoracostomy.
Methods
A literature search was conducted to identify the published research; a critical appraisal of the research identified was then conducted using CASP tools.
Results
Reasons to use a drain
If the pneumothorax is initially >1.5 cm in size, the patient needs a chest drain insertion.
If the patient is haemodynamically unstable or has a multitude of other injuries, the patient needs a chest drain.
If the patient requires IPPV (intermittent positive pressure ventilation), a chest drain is always required, due to increased risk of a tension pneumothorax developing.
If the patient is symptomatic from the traumatic pneumothorax, especially if they are older.
Only 10% of patients initially managed conservatively then go onto have a drain inserted.
Reasons not to use a drain
Small to moderate-sized pneumothorax.
Some types of pneumothorax can resolve spontaneously; Patients are very unlikely to deteriorate clinically if monitored when undergoing conservative management.
CT scan usage increasing; CT has become cheaper and therefore more widely utilised CT is available 24/7.
Shorter average hospital stay – 12.9 vs 17.6 days for conservative vs drain.
Conclusions
Conservative management can be the appropriate treatment in small to moderate-sized pneumothorax, with 1.5 cm being the cut-off point.
Size cannot be the only factor to determine the best treatment; is the patient haemodynamically stable with few symptoms?
Other factors which must be included are if there are other injuries present, or whether they may need IPPV, as these can increase the risk of complications such as a tension pneumothorax.
Clear guidelines need to be established so that junior medical staff can refer to a policy which can aid their clinical decision-making process.
- © Royal College of Physicians 2016. All rights reserved.
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