slide1
Download
Skip this Video
Download Presentation
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

Loading in 2 Seconds...

play fullscreen
1 / 33

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 - PowerPoint PPT Presentation


  • 62 Views
  • Uploaded on

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. Tobias Lindner Emergency Dpt.- Trauma Wing. Diagnostics ….. WHAT DO WE HAVE ?. clinicial examination chest film ultrasound CT. Diagnostics ….. clinical examination.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' 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' - gen


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
slide1

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

Tobias Lindner

Emergency Dpt.- Trauma Wing

diagnostics what do we have
Diagnostics ….. WHAT DO WE HAVE ?
  • clinicial examination
  • chest film
  • ultrasound
  • CT
diagnostics clinical examination
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

diagnostics chest film
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

slide7

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

Diagnostics ….. ultrasound…….

B- mode

M- mode, sliding lung sign

seahore- sign

comet- trail- artifacts

stratosphere- sign

reverberations

slide8

Diagnostics ….. ultrasound…….

  • 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

8

slide9

Diagnostics ….. ultrasound……

  • 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

slide10

Ding et al., CHEST. 2011

Diagnostics ….. ultrasound……

  • 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
slide11

Diagnostics …..

however……….

does not favor ultrasound in diagnosing spontaneous PTX – results too conflicting

(for them !)

slide12

Diagnostics …..

......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
therapy guidelines
Therapy…..Guidelines ?

Primary &

Secondary Spontaneous Pneumothorax (PSP/SSP)

slide14

2001

&

2010

slide15

Therapy……PSP (small, stable)

  • small* vs large
  • stable** vs unstable

*apex/ cupula distance

< 3cm on chest film

**resp. rate < 24/ min., hr > 60/ min. and < 120 /min., bp normal, O2 sat. room air > 92 %

  • observation in ER for 3-6 hrs.
  • check x- ray
  • DISCHARGE (if unchanged)
  • small* vs large
  • clinical compromise

breathlessness ? **

*hilum to lateral chest wall < 2 cm on chest film

**not definded

slide16

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 &/orbreathless:

  • needleaspiration
  • discharge after

check x- ray

slide17

Therapy…….SSP

stable, small:

  • observation or tube
  • fatal cases during observation reported !!!

(O´Rourke. Chest. 1989)

all others:

  • chest tube
  • admit all !

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 !
slide18

Bringing it together……

  • (needle aspiration)
  • small- bore catheter (< 14F)
  • chest tube (16- 28F)

2001

  • 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)

2010

slide19

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

slide20

NA vs Chest tube in PSP

  • 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.

slide21

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 !
slide22

chest drain removal:

  • clamping is generally unnecessary
  • period without suction before removal
  • 41 % of panel members do clamp
  • all check CR before removal
  • 63 % after 13-23hrs after last evidence of air leak
traumatic ptx
Traumatic PTX

general remarks:

  • 2nd rank of injury after

chest trauma (after rib fx)

  • relevant prehospital Dx !
diagnostics clinical examination1
Diagnostics …..clinical examination

might be (more) reliable in trauma than in spontaneous Ptx !

traumatic ptx diagnostics
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

diagnostics ultrasound
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

diagnostics what else is on the horizon
Diagnostics …..what else is on the horizon ?
  • micropower impulsed radar/ultrashort radar pulse
  • spatial accuracy of approx. 5mm
slide28

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 ?
slide29

Diagnostics …..what else is on the horizon ?

  • promising !
  • easy, quick, repeatable, not this operator depended, objective !
  • INDEPENDENT from preclinical setting !
therapy traumatic ptx
Therapy –Traumatic PTX
  • should all be treated with

chest drains !

  • air & blood !
  • 28- 36 F !
slide31

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 !
ad