1. U N I V E R S I T Ä T S M E D I Z I N B E R L I N Tobias Lindner Emergency Dpt.- Trauma Wing Pneu Concepts in Pneumothorax

2. U N I V E R S I T Ä T S M E D I Z I N B E R L I N Diagnostics ….. WHAT DO WE HAVE ?  clinicial examination  chest film  ultrasound  CT

3. U N I V E R S I T Ä T S M E D I Z I N B E R L I N Diagnostics ….. clinical examination auscultation alone is not reliable !  118 patients, penetrating chest injury  71 (60%) with Ptx  30 of these (42%) not diagnosed by inhospital auscultation ! (control: chest radiograph !) Chen et al. : Hemopneumothorax missed by auscultation in penetrating chest injury. J Trauma. 1997

4. U N I V E R S I T Ä T S M E D I Z I N B E R L I N Diagnostics ….. chest film…… ….. there is a problem: occult pneumothorax  109 patients after chest trauma  only 13 of 25 PTXs detected by supine ap chest film (control: CT)  sensitivity 52%, specifity 100 % Soldati et al. : Occult traumatic pneumothorax: diagnostic accuracy of lung ultrasonography in the emergency department. Chest. 2008

5. U N I V E R S I T Ä T S M E D I Z I N B E R L I N blunt chest trauma, cyclist hit by car Diagnostics ….. chest film……

6. U N I V E R S I T Ä T S M E D I Z I N B E R L I N blunt chest trauma, pedestrian hit by metal from lorry Diagnostics ….. chest film……

7. U N I V E R S I T Ä T S M E D I Z I N B E R L I N Diagnostics ….. ultrasound……. Ouellet J-F et al., The sonographic diagnosis of pneumothorax. J Emerg Trauma Shock. 2011 Stone MB et al., The heart point sign: description of a new ultrasound finding suggesting pneumothorax. Acad Emerg Med. 2010 seahore- sign stratosphere- sign M- mode, sliding lung sign comet- trail- artifacts reverberations B- mode

8. U N I V E R S I T Ä T S M E D I Z I N B E R L I N 8  M- and B- mode, 3 min. per side, convex probe  operators at least 1 year experience (ER personnel)  23 of 25 PTXs detected by ultrasound (remember: only 13 by ap chest film !)  92 % sensitivity, 99.4 % specifity, NPV 98,9 Soldati et al., Occult traumatic pneumothorax: diagnostic accuracy of lung ultrasonography in the emergency department. Chest. 2008 Diagnostics ….. ultrasound…….

9. U N I V E R S I T Ä T S M E D I Z I N B E R L I N  evidence based review (chest ap radiograph vs US)  4 prospective studies, gold standard: CT  606 patients, blunt trauma cases  US: sensitivity 86- 98 %, specifity 97- 100 %  chest ap supine: sensitivity 28-75 %, specifity 100 % RG Wilkerson et al., Sensitivity of Bedside Ultrasound and Supine Anteroposterior Chest Radiographs for the Identification of Pneumothorax After Blunt Trauma. Acad Emerg Med.. 2010 Diagnostics ….. ultrasound……

10. U N I V E R S I T Ä T S M E D I Z I N B E R L I N  20 studies, US: pooled sensitivity/ specifity = 88/ 99 % (CR: pooled sensitivity/ specifity = 52/ 100 %)  bedside US performed by clinicians had higher sensitivity and similar specificity compared to CR  US depended on the skill of the operators  US is reliable & advantage of portability, rapidity and non biological invasive Diagnostics ….. ultrasound…… Ding et al., CHEST. 2011

11. U N I V E R S I T Ä T S M E D I Z I N B E R L I N however………. does not favor ultrasound in diagnosing spontaneous PTX – results too conflicting (for them !) Diagnostics …..

12. U N I V E R S I T Ä T S M E D I Z I N B E R L I N......instead:  standard erect chest x- ray in inspiration (SP)  lateral views might be helpful, but no routine  expiratory films without additional benefit  in doubt : CT Diagnostics …..

13. U N I V E R S I T Ä T S M E D I Z I N B E R L I N Therapy…..Guidelines ? Primary & Secondary Spontaneous Pneumothorax (PSP/SSP)

14. U N I V E R S I T Ä T S M E D I Z I N B E R L I N 2001 2010 &

15. U N I V E R S I T Ä T S M E D I Z I N B E R L I N Therapy……PSP (small, stable)  small* vs large  stable** vs unstable *apex/ cupula distance < 3cm on chest film **resp. rate 60/ min. and 92 %  small* vs large  clinical compromise breathlessness ? ** *hilum to lateral chest wall < 2 cm on chest film **not definded  observation in ER for 3-6 hrs.  check x- ray  DISCHARGE (if unchanged)

16. U N I V E R S I T Ä T S M E D I Z I N B E R L I N Therapy…..PSP (large, stable/unstable) stable & large:  small- bore catheter (< 14 F) or chest tube (16-22F)  discharge possible with Heimlich valve unstable & large:  small- bore catheter or chest tube  admit ! >2cm &/or breathless:  needle aspiration  discharge after check x- ray

17. U N I V E R S I T Ä T S M E D I Z I N B E R L I N stable, small:  observation or tube  fatal cases during observation reported !!! (O´Rourke. Chest. 1989) all others:  chest tube  admit all ! Therapy…….SSP only in < 1 cm without compr.:  consider observation or NA size 1-2 cm/ not breathless:  needle aspiration 2cm at level of hilum &/or breathless:  small bore catheter  admit all !

18. U N I V E R S I T Ä T S M E D I Z I N B E R L I N  (needle aspiration)  small- bore catheter (< 14F)  chest tube (16- 28F)  needle aspiration 1st choice, unless:  bilateral PTX  SSP and > 2cm at level of hilum on CR  small bore chest drains (8-14F) (generally, no need for larger bore catheters in all spontaneous PTX) 2001 2010 Bringing it together……

19. U N I V E R S I T Ä T S M E D I Z I N B E R L I N NA vs Chest tube in PSP  1 included study, total of 60 patients  27 underwent simple aspiration  33 underwent intercostal tube drainage  no significant difference with regard to: immediate, one week or one year success rate  simple aspiration is associated with a reduction in hospitalization rate (53 vs 100 %) Wakai et al., Simple aspiration versus intercostal tube drainage for primary spontaneous pneumothorax in adults. Cochrane review. 2007. Based on: Noppen 2002

20. U N I V E R S I T Ä T S M E D I Z I N B E R L I N  review  NA as safe and successful as tube thoracostomy  fewer hospital admissions after NA  shorter hospital stays (if admitted) Zehtabchi et al., Management of Emergency Medicine Department Patients With Primary Spontaneous Pneumothorax : Needle Apsiration or Tube Thoracostomy ? Ann of Emerg. Med.. 2008.  review  NA might fail in larger PTX  also SSP studies included ! Chan et al., The Role of Simple Aspiration in the Management of Primary Spontaneous Pneumothorax, J of Emerg. Med., 2008. NA vs Chest tube in PSP

21. U N I V E R S I T Ä T S M E D I Z I N B E R L I N general remarks:  supplementary O2 therapy (at least 24 h) - increases resolution rate by reduction of nitrogen partial pressure  no flights until then plus 1 week, but: generally, recurrence risk drops sign. only after 1 year !  no diving unless bilateral pleurodesis !

22. U N I V E R S I T Ä T S M E D I Z I N B E R L I N chest drain removal:  41 % of panel members do clamp  all check CR before removal  63 % after 13-23hrs after last evidence of air leak  clamping is generally unnecessary  period without suction before removal

23. U N I V E R S I T Ä T S M E D I Z I N B E R L I N Traumatic PTX general remarks:  2nd rank of injury after chest trauma (after rib fx)  relevant prehospital Dx !

24. U N I V E R S I T Ä T S M E D I Z I N B E R L I N Diagnostics ….. clinical examination might be (more) reliable in trauma than in spontaneous Ptx !

25. U N I V E R S I T Ä T S M E D I Z I N B E R L I N Traumatic PTX- Diagnostics  synopsis of auscultation, respiratory rate /shortness of breath. diagnostic accuracy can be improved by combining these three signs…… (and putting hands on ! ) Waydhas et al.,Prehospital pleural decompression and chest tube placement after blunt trauma: A systematic review. Resuscitation. 2007.  ……..but still: clinical examination is very variable…..  ……. need of: safe, objective method independent from setting German Guideline on Polytraumamanagement- Prehospital Section, 2010

26. U N I V E R S I T Ä T S M E D I Z I N B E R L I N Diagnostics ….. ultrasound……  prehospital: possible as on scene method but still skill dependend ! Kirkpatrick et al., Hand- Held Thoracic Sonography for Detecting Post- Traumatic Pneumothoraces: The Extended Focused Assessment With Sonography for Trauma. J of Trauma. 2004 Walcher et al., Optimierung desTraumamanagements durch präklinische Sonographie. Unfallchirurg. 2002

27. U N I V E R S I T Ä T S M E D I Z I N B E R L I N Diagnostics …..what else is on the horizon ?  micropower impulsed radar/ultrashort radar pulse  spatial accuracy of approx. 5mm

28. U N I V E R S I T Ä T S M E D I Z I N B E R L I N Diagnostics …..what else is on the horizon ?  portable/ point of care  non- invasive  easy  1-2 min. scan time  skin contact unnecessary  penetrate through clothing  ? specific location and volume ?

29. U N I V E R S I T Ä T S M E D I Z I N B E R L I N Diagnostics …..what else is on the horizon ?  promising !  easy, quick, repeatable, not this operator depended, objective !  INDEPENDENT from preclinical setting !

30. U N I V E R S I T Ä T S M E D I Z I N B E R L I N Therapy –Traumatic PTX  should all be treated with chest drains !  air & blood !  28- 36 F !

31. U N I V E R S I T Ä T S M E D I Z I N B E R L I N Pneu Concepts in Pneumothorax  US is accepted (in experienced operators hands) for diagnosing PTX  needle aspiration is the evolving method of choice for active intervention in MOST spontaneous PTx !?  there is an urgent need for a easy & objective tool for PTX diagnostics in the prehospital setting !

32. U N I V E R S I T Ä T S M E D I Z I N B E R L I N

33. Danke !