CXR

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CXR is typically the initial diagnostic study used to assess for pneumothorax. On a plain chest film, pneumothorax appears as increased lucency of lung fields with a pleural line, which appears as a clearly demarcated line with air on either side.$^{17}$ For large pneumothoraces in patients who are in apparent clinical distress, this is generally a reliable diagnostic study. However, there are several limitations of plain radiographs for diagnosis of pneumothorax.

Although upright plain films are more sensitive and specific than supine films due to improved visualization of the pleural lines, pericardial silhouette, and lung-field hyperlucency, upright radiographs may not be possible if the patient is in extremis or otherwise unable to be seated upright in the trauma setting due to hemodynamic instability, orthopedic concerns, or cervical spine precautions.$^5$ This makes the study particularly less sensitive for detection of smaller pneumothoraces.$^5$ However, even supine CXRs require placement of a detector underneath the patient, which may require rolling or otherwise repositioning the patient. CXR can be time-consuming to prepare and set up, and often require that healthcare personnel either wear lead shields or vacate the room while the x-ray is taken, which can delay further workup and leaves the patient alone for the duration of the study.$^8$

Various methods may be utilized by radiology to quantify the size of a pneumothorax on plain films, including the Collins method, the Rhea method, the Light Index, and guidelines from the American Thoracic Society and the British Thoracic Society. (Figure 3.) It is worth noting that often, these formal measures are less important clinically in a radiographic report than the qualitative description of pneumothoraces as “small” or “large,” and these definitions can vary greatly between institutions. Emergency clinicians should also rely on clinical gestalt to approach management of pneumothoraces.

For tension pneumothoraces and larger pneumothoraces in symptomatic patients, TT is the definitive treatment for air evacuation. The chest tube should be placed at the midaxillary line in the fourth or fifth intercostal space with the tube directed anteriorly to allow for drainage of the pneumothorax.$^{26}$ Standard chest tube size ranges from 28F to 40F; pigtail chest tube size generally ranges from 8F to 20F.$^{26}$

Positioning and adequate analgesia are central to successful placement of a chest tube. The patient’s arm should be positioned above the head to allow full access to the lateral chest wall. The skin should be anesthetized where the incision will be made, and lidocaine should be administered along the entire tract that the chest tube will traverse, from skin to parietal pleura. The rib periosteum and the parietal pleura are pain-sensitive structures that require a large amount of local anesthetic.

Patients undergoing TT should be counseled on tube-related complications, as well as the possible need for the insertion of additional chest tubes. (See Table 2.) The most common complications associated with chest tube insertion are bleeding and intercostal neuralgia, although there are also more-severe and morbid complications that can occur due to improper positioning or premature tube removal.$^{27}$ Risk of damage to surrounding structures can be minimized with proper insertion technique. Although re-expansion pulmonary edema is a rare complication, it carries a high degree of morbidity and mortality.$^{26}$

Data from Mohammed HM. Chest tube care in critically ill patient: a comprehensive review. Egyptian Journal of Chest Diseases and Tuberculosis. 2015;64(4):849-855.