From the Department of Surgery (G.B., C.M.C., A.T., G.P.V.), University of California, San Francisco, East Bay, Oakland; Chemical Sciences Division (J.Y.C.), Lawrence Berkeley National Laboratory, Berkeley, California.
J Trauma Acute Care Surg. 2022 Jan 1;92(1):177-184. doi: 10.1097/TA.0000000000003415.
Guidelines for penetrating occult pneumothoraces (OPTXs) are based on blunt injury. Further understanding of penetrating OPTX pathophysiology is needed. In observational management of penetrating OPTX, we hypothesized that specific clinical and radiographic features may be associated with interval tube thoracostomy (TT) placement. Our aims were to (1) describe OPTX occurrence in penetrating chest injury, (2) determine the rate of interval TT placement in observational management and clinical outcomes compared with immediate TT placement, and (3) describe risk factors associated with failure of observational management.
Penetrating OPTX patients presenting to our level 1 trauma center from 2004 to 2019 were reviewed. Occult pneumothorax was defined as a pneumothorax on chest computed tomography but not on chest radiograph. Patient groups included immediate TT placement versus observation. Clinical outcomes compared were TT duration and complications, need for additional thoracic procedures, length of stay (LOS), and disposition. Clinical and radiographic factors associated with interval TT placement were determined by multivariable regression.
Of 629 penetrating pneumothorax patients, 103 (16%) presented with OPTX. Thirty-eight patients underwent immediate TT placement, and 65 were observed. Twelve observed patients (18%) needed interval TT placement. Regardless of initial management strategy, TT placement was associated with longer LOS and more chest radiographs. Chest injury complications and outcomes were similar. Factors associated with increased odds of interval TT placement included Chest Abbreviated Injury Scale score of ≥4 (adjusted odds ratio [aOR], 7.38 [95% confidence interval, 1.43-37.95), positive pressure ventilation (aOR, 7.74 [1.07-56.06]), concurrent hemothorax (aOR, 6.17 [1.08-35.24]), and retained bullet fragment (aOR, 11.62 [1.40-96.62]) (all p < 0.05).
The majority of patients with penetrating OPTX can be successfully observed with improved clinical outcomes (LOS, avoidance of TT complications, reduced radiation). Interval TT intervention was not associated with risk for adverse outcomes. In patients undergoing observation, specific clinical factors (chest injury severity, ventilation) and imaging features (hemothorax, retained bullet) are associated with increased odds for interval TT placement, suggesting need for heightened awareness in these patients.
Prognostic, level IV.
针对隐匿性气胸（OPTX）的治疗指南主要基于钝性创伤。需要进一步了解穿透性 OPTX 的病理生理学。在穿透性 OPTX 的观察性管理中，我们假设特定的临床和影像学特征可能与间隔性胸腔引流管（TT）放置相关。我们的目的是：（1）描述穿透性胸部损伤中 OPTX 的发生情况；（2）确定观察性管理中间隔 TT 放置的发生率以及与立即 TT 放置的临床结果比较；（3）描述与观察性管理失败相关的危险因素。
回顾 2004 年至 2019 年期间我院收治的穿透性 OPTX 患者。隐匿性气胸定义为 CT 上有气胸而 X 线上没有气胸。患者分为立即 TT 放置组和观察组。比较的临床结果包括 TT 持续时间和并发症、是否需要其他胸部操作、住院时间（LOS）和出院情况。通过多变量回归确定与间隔 TT 放置相关的临床和影像学因素。
在 629 例穿透性气胸患者中，103 例（16%）为 OPTX。38 例患者行立即 TT 放置，65 例患者接受观察。12 例观察组患者（18%）需要间隔 TT 放置。无论初始管理策略如何，TT 放置均与 LOS 延长和更多的 X 线检查相关。胸部损伤并发症和结局相似。与间隔 TT 放置可能性增加相关的因素包括胸损伤严重程度评分≥4（校正优势比[OR]，7.38[95%置信区间，1.43-37.95]）、正压通气（OR，7.74[1.07-56.06]）、并发血胸（OR，6.17[1.08-35.24]）和残留弹片（OR，11.62[1.40-96.62]）（均 P<0.05）。
大多数穿透性 OPTX 患者可通过改善临床结局（LOS、避免 TT 并发症、减少辐射）成功接受观察。间隔 TT 干预与不良结局风险无关。在接受观察的患者中，特定的临床因素（胸部损伤严重程度、通气）和影像学特征（血胸、残留弹片）与间隔 TT 放置的可能性增加相关，这表明这些患者需要更高的警惕性。
预后，IV 级。
