Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.
AJR Am J Roentgenol. 2011 Jul;197(1):122-4. doi: 10.2214/AJR.10.5856.
The purpose of this prospective study was to determine the incidence and clinical significance of pneumothoraces detected on routine radiography after chest tube removal following cardiac surgery and correlate those findings with an immediate postprocedure assessment of the likelihood of new pneumothorax.
Routine portable chest radiographs obtained after chest tube removal in 400 consecutive cardiac surgery patients were assessed by a radiologist to determine the incidence and grade of pneumothoraces and were correlated with the clinical estimation of the likelihood of this complication, and whether the radiographic finding changed medical management or led to surgical intervention.
Of 9.3% of cases (37/400) of new pneumothoraces after chest tube removal, 70.3% were tiny (barely perceptible), 27.0% were small (< 1 cm from the pleural line to the apex of the hemithorax), and 2.7% were medium (6-10 cm from the pleural line to the apex of the hemithorax). The incidences of small and medium pneumothoraces were substantially greater in patients with higher levels of clinical suspicion. All tiny pneumothoraces had no clinical importance. Not obtaining routine chest radiographs after chest tube removal in the 345 patients (86.3%) with the lowest level of clinical suspicion would have resulted in missing six small pneumothoraces (1.7%), none of which led to medical or surgical intervention or a delay in discharge.
Chest radiography performed after chest tube removal following cardiac surgery is necessary only if the patient has respiratory or hemodynamic changes or if there are problems with the technical aspect of chest tube removal. Following this guideline in our patient population could have eliminated 86.3% of radiographs without missing any clinically significant pneumothoraces.
本前瞻性研究旨在确定心脏手术后拔除胸腔引流管后常规胸片上发现气胸的发生率和临床意义，并将这些发现与即刻术后新发气胸可能性的评估相关联。
对 400 例连续心脏手术患者拔除胸腔引流管后的常规便携式胸片进行评估，由放射科医生评估气胸的发生率和程度，并与对该并发症发生可能性的临床评估进行相关性分析，以及影像学发现是否改变了治疗方案或导致了手术干预。
在拔除胸腔引流管后新发气胸的 9.3%（37/400）病例中，70.3%为微小气胸（几乎不可察觉），27.0%为小气胸（<胸壁线至半胸顶 1cm），2.7%为中量气胸（6-10cm 胸壁线至半胸顶）。在临床怀疑程度较高的患者中，小和气胸的发生率显著更高。所有微小气胸均无临床意义。对临床怀疑程度最低的 345 例患者（86.3%）不进行常规拔除胸腔引流管后的胸部 X 线检查，可能会漏诊 6 例小气胸（1.7%），均无需进行医疗或手术干预或延迟出院。
只有当患者出现呼吸或血流动力学改变，或在拔除胸腔引流管的技术方面存在问题时，才需要在心脏手术后拔除胸腔引流管后进行胸部 X 线检查。遵循这一指导原则，我们的患者人群中可以减少 86.3%的 X 线检查，而不会漏诊任何有临床意义的气胸。
