Ultrasound May Safely Replaces Chest Radiograph After Tube Thoracostomy Removal in Trauma Patients

Elsevier

Available online 17 September 2022

InjuryABSTRACTIntroduction

: A chest radiograph (CXR) is routinely obtained in trauma patients following tube thoracostomy (TT) removal to assess for residual pneumothorax (PTX). New literature supports the deference of a radiograph after routine removal procedure. However, many surgeons have hesitated to adopt this practice due to concern for patient welfare and medicolegal implications. Ultrasound (US) is a portable imaging modality which may be performed rapidly, without radiation exposure, and at minimal cost. We hypothesized that transitioning from CXR to US following TT removal in trauma patients would prove safe and provide superior detection of residual PTX.

Materials and Methods

: A practice management guideline was established calling for the performance of a CXR and bedside US 2 hours after TT removal in all adult trauma patients diagnosed with PTX at a level 1 trauma center. Surgical interns completed a 30-minute, US training course utilizing a handheld US device. US findings were interpreted and documented by the surgical interns. CXRs were interpreted by staff radiologists blinded to US findings. Data was retrospectively collected and analyzed.

Results

: Eighty-nine patients met inclusion criteria. Thirteen (15%) post removal PTX were identified on both US and CXR. An additional 11 (12%) PTX were identified on CXR, and 5 (6%) were identified via US, for a total of 29 PTX (33%). One patient required re-intervention; the recurrent PTX was detected by both US and CXR. For all patients, using CXR as the standard, US displayed a sensitivity of 54.2%, specificity of 92.3%, negative predictive value of 84.5%, and positive predictive value of 72.2%. The cost of care for the study cohort may have been reduced over $9,000 should US alone have been employed.

Conclusion

: Bedside US may be an acceptable alternative to CXR to assess for recurrent PTX following trauma TT removal.

Section snippetsINTRODUCTION

Tube thoracostomy (TT) placement is one of the most common procedures performed by trauma surgeons. Despite this, an optimal imaging protocol for detection of recurrent pneumothorax (PTX) after TT removal has yet to be standardized [1,2]. In most trauma centers, a routine chest radiograph (CXR) is obtained hours after TT removal to assess for recurrent pneumothorax. However, CXR is a poor evaluator of apical and small sized PTX and a significant number of these PTX are missed [3]. Fortunately,

MATERIALS AND METHODS

Following institutional review board approval, a retrospective review of all adult trauma patients admitted to the trauma service at an American College of Surgeons (ACS)-verified level 1 trauma center with PTX undergoing TT was conducted from November 2020 to September 2021. The study was conducted in a prospective, blinded manner. Pregnant patients, patients with medical devices placed on the side of tube thoracostomy limiting US, and those with chest wall injury precluding adequate US were

RESULTS

A total of 89 patients underwent ultrasound evaluation for pneumothorax during the study period. No patients met exclusion criteria. The tube thoracostomy removal protocol was followed for each patient in the cohort. All ultrasounds were performed by postgraduate year (PGY) 1 residents.

Table 1 presents the demographic, injury, and outcome data for the total patient cohort. The patients were majority male (n=66, 74%) with mean age of 47.1 and BMI of 26.0. A blunt mechanism of injury was most

DISCUSSION

Bedside, handheld US may be an acceptable alternative to post-removal CXR to assess for recurrent PTX following trauma TT removal and potentially offers multiple patient benefits to include decreased radiation exposure, time to imaging interpretation (potentially reducing hospital LOS) and cost. Only one clinically significant PTX occurred in this study, and it was identified by both imaging modalities. A 2021 systematic review published in the Journal of Trauma and Acute Care Surgery revealed

CONCLUSIONS

Overall, US provides a safe alternative to routine CXR in trauma TT removal. Additional, more robust and multicenter studies are needed to further investigate replacing CXR with US in trauma TT removal protocols. The practice management guideline continues at our institution, and data collection is ongoing. Further studies to investigate forgoing imaging of any modality after trauma TT removal are also warranted, but, perhaps ultrasound provides the trauma community with a safe and reliable

AUTHOR CONTRIBUTIONS

Principal Investigator – VM

Literature Search – MVPM, LEF, DBB, EC, KH

Study Design – VM, MVPM, LEF, DBB, EC

Data Collection – MVPM, LEF, DBB, EC

Data Analysis – MVPM, LEF, EC, DBB, KH, AW, VM

All authors participated in the interpretation of the results and contributed significantly to the writing and critical revision of this manuscript.

Funding

This research did not receive any specific grant funding from funding agencies in the public, commercial or not-for-profit sectors

CONFLICTS OF INTEREST

The authors declare no conflicts of interest.

REFERENCES (12)

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