EVALUATION OF THE ROLE OF BEDSIDE

ULTRASONOGRAPHY IN THE
DETECTION OF TRAUMATIC OCCULT
PNEUMOTHORAX
HEBA EZZAT A, MOHAMED ELKAHWAGY B, *, MOHAMED ELTOMEY C, MOHAB SABRY B

A EMERGENCY MEDICINE AND TRAUMATOLOGY DEPARTMENT, FACULTY OF MEDICINE, TANTA UNIVERSITY, EGYPT B CARDIO-THORACIC
SURGERY DEPARTMENT, FACULTY OF MEDICINE, TANTA UNIVERSITY, EGYPT
C DIAGNOSTIC RADIOLOGY DEPARTMENT, FACULTY OF MEDICINE, TANTA UNIVERSITY, EGYPT

H. Ezzat et al. / Journal of the Egyptian Society of Cardio-Thoracic Surgery 26 (2018) 146e150
 INTRODUCTION

• Primary management of pneumothorax (PTX)  usually as simple as it can be

done by junior physician but diagnosis of pneumothorax is sometimes as difficult as it
can be missed by senior physician and lead to serious complications that may
endanger life of the patient.
• Primary survey for trauma patient includes chest X ray and it is usually the main
investigation for detection of pneumothorax but with the improvement of radiological
methods and introduction of chest computed tomography (CT) as an available tool
for diagnosis it was shown to be more accurate [2].

[2] Wicky S, Wintermark M, Schnyder P, et al. Imaging of blunt chest trauma. Eur Radiol 2000;10(10):1524e38.
 INTRODUCTION

• Occult pneumothorax (OPTX)  a pneumothorax that is diagnosed by CT scan

of the chest without previous identification or clinical suspicion by traditional chest X
ray and its current prevalence stands at 2%e15% [3].
• OPTX could be classified according to CT chest findings
• Small: equal or less than 10 mm thick with a height equal or less than 40 mm
• Moderate: more than 10 mm thick with a height more than 40 mm but did not extend
posterior to the midthoracic coronal line
• Large: more than 10 mm thick with a height more than 40 mm (seen on 4 or more
contiguous 10-mm CT slices) and extended posterior to the midthoracic coronal line [5].
[3] Moore FO, Goslar PW, Coimbra R, et al. Blunt traumatic occult pneumothorax: is observation safe? Results of a
prospective, AAST multicenter study. J Trauma 2011;70:1019e23.
[5] Ryan KL, Colin A, Janice HH, et al. Occult pneumothoraces in Chinese patients with significant blunt chest trauma:
radiological classification and proposed clinical significance. J Inj 2012;43:2015e8.
 INTRODUCTION

• Ultrasound had been used in a wide variety of specialties and had great improvement in
the last decade as it always available in emergency department and ultrasound machines
had become more compact and portable. [6,7].
• The aim of the study  to evaluate the role of bedside thoracic
ultrasonography (U/S) for detection of occult pneumothorax in patients with
chest trauma.

[6] Moore CL, Copel JA. Point-of-Care ultrasonography. N Engl J Med 2011;364(8):749e57.
[7] Ko€rner M, Krotz MM, Degenhart C, et al. Current role of emergency US in patients with major trauma. Radiographics
2008;28(1):225e42.
PATIENTS AND
METHODS
 STUDY POPULATION AND ELIGIBILITY

• This study was conducted on 80 polytraumatized adult patients (more than 18

years) recently (within the same day of trauma) presented to the Emergency
Department, Tanta University Hospitals, Egypt with chest trauma in the period between
October 2016 to the end of January 2018.
• Patients with haemodynamic instability hindering transportation and endangering the life
were excluded.
• Chest X ray on admission showed no obvious signs of pneumothorax.
METHODS

• All of those 80 patients enrolled in the study were subjected to chest X-ray either in
erect position (when possible) or supine position revealing no pneumothorax.
• All patients were subjected to chest X-ray either erect position when possible or supine
position revealing no pneumothorax  all of those patients underwent thoracic
ultrasonography prior to whole body CT scanning performed within 2 h of
admission.
• Subsequently, all of those patients underwent thoracic U/S examination using Digital
Ultrasonic Imaging System Model Phillips Affiniti 50G and portable Mindray dp20 prior to
whole body CT scanning performed by Toshiba Alicson 16 slice within 2 h of admission.
 METHODS

• The characteristic ultrasonographic features for detection of pneumothorax in this study

were: absence of lung sliding, absence of B lines and identification of the lung
point on 2D and M-mode ultrasonography [8].
• OPTX distribution was described by patient side (unilateral or bilateral), as well as by
location in the hemithorax into apical (superior to the manubrium or first rib),
basal (touching the diaphragm), medial (crossing the mid-coronal line medial to the lung
parenchyma) and lateral (crossing the midcoronal line lateral to the lung parenchyma)
[9].
[8] Abdulrahman Y, Musthafa S, Hakim SY, et al. Utility of extended FAST in blunt chest trauma: is it the time to be used in the
ATLS algorithm? World J Surg 2015;39(1):172e8.
[9] Chad G, Andrew W, Kevin B, et al. Factors related to the failure of radiographic recognition of occult posttraumatic
pneumothoraces. Am J Surg 2005; 189(5):541e6.
STATISTICAL ANALYSIS

• Statistical presentation and analysis of the present study was conducted using the mean,
standard deviation (SD), student's T test (t-test), Chi-square (X2), analysis of
variance (ANOVA), and Roc curve tests.
• A probability value (P value) less than 0.05 was considered statistically significant.
• All statistical calculations were done using SPSS (Statistical Package for Social Science
“SPSS” for IBM, USA) version 23 for Microsoft Windows.
RESULTS
RESULTS

• This prospective study was conducted on 80 polytraumatized adult patients admitted

consequently to Tanta University Hospital, Egypt.
• All of those patients were subjected to chest X ray on admission revealing no pneumothorax but
subsequent thoracic CT scan detected OPTX in 62 patients (77.5%).
• Chest U/S was performed for all patients of the study.
• The main three signs for diagnosis of pneumothorax by ultrasound were absent lung sliding, absent B
lines, and visualizing lung point.
• To summarize, only 16 patients were negative for OPTX by both CT and U/S, 56 patients were
positive for OPTX by both techniques, 2 patients were positive by U/S and negative by CT and 6
patients were negative by U/S and positive by CT (Total 80 patients).
DISCUSSION
 DISCUSSION

• Occult (radiographically not interpreted) pneumothorax that appears in CT chest could progress
into tension type endangering the life [4].
• Chest X ray had many fallacies in diagnosis of pneumothorax specially when the patient is severely
injured and cannot be put in erect position. On the other hand, U/S is rapid, easily portable and could be a
useful tool in detection of pneumothorax in ICU patients avoiding transportation to CT imaging room [11].
• On this track, 80 adult polytraumatized patients were surveyed for detection of OPTX.
• The characteristic features for diagnosis of pneumothorax by thoracic U/S consists mainly of 3 signs which are
absence of lung sliding (horizontal lines that are brightly echogenic and located between the rib shadows),
absence of B lines (multiple ray-like, or comet-tail, vertical lines extending from pleural line to lower edge of
screen without fading) and presence of lung point (location where the lung adheres to the parietal pleura)
[8].
[4] Ball CG, Hameed SM, Evans D, et al. Occult pneumothorax in the mechanically ventilated trauma patient. Can J Surg 2003;46:373e9.
[11] Lichtenstein DA. Lung ultrasound in the critically Ill. Ann Intensive Care 2014;4(1):1.
[8] Abdulrahman Y, Musthafa S, Hakim SY, et al. Utility of extended FAST in blunt chest trauma: is it the time to be used in the ATLS algorithm? World J Surg
2015;39(1):172e8.
 DISCUSSION

• In this study, U/S detected pneumothorax in 56 out of 62 patients having OPTX by CT

with sensitivity up to 90.32% and positive predictive value of 96.55%.
• On the other hand, U/S succeeded in exclusion of OPTX in 16 out of 18 patients that
were free of OPTX in their CT with specificity reaching 88.89% and negative
predictive value of 72.73%, the overall accuracy was calculated to be 90%.
• In his study enrolling 382 patients, Dulchavsky et al. found that U/S had a slightly
higher sensitivity of 95.5% and a more specificity of 100% for the detection of
pneumothorax [12].
[12] Dulchavsky SA, Schwarz KL, Kirkpatrick AW, et al. Prospective evaluation of thoracic ultrasound in the detection of
pneumothorax. J Trauma Acute Care Surgery 2001;50(2):201e5.
 DISCUSSION

• After one year, Rowan et al. came with both higher sensitivity and specificity
(100% and 93.8% respectively) in detection of traumatic pneumothorax by chest U/S
[13].
• Accomplishing their work on 300 patients, Knudtson et al. noticed higher sensitivity,
specificity and negative predictive value of 99.7%, 99.7% and 99.4% respectively in
revealing of pneumothorax by chest U/S [14].
• Using high resolution ultrasound for detection of pneumothorax after
transthoracic needle aspiration, Chung et al. documented 80% sensitivity, 94%
specificity and diagnostic accuracy of 89% [15].
[13] Rowan KR, Kirkpatrick AW, Liu D, et al. Traumatic pneumothorax detection with thoracic US: correlation with chest radiography and CTdInitial
experience. Radiology 2002;225(1):210e4.
[14] Knudtson JL, Dort JM, Helmer SD, et al. Surgeon-performed ultrasound for pneumothorax in the trauma suite. J Trauma Acute Care Surgery 2004;
56(3):527e30.
[15] Chung MJ, Goo JM, Im JG, et al.Value of high-resolution ultrasound in detecting a pneumothorax. Eur Radiol 2005;15(5):930e5.
 DISCUSSION

• Aiming to assess the size of pneumothorax, Zhang et al. evaluated the sensitivity,
the specificity and the accuracy of chest U/S to be 86.2%, 97.2% and 94.8% respectively
[16].
• The lowest sensitivity of chest US in detection of pneumothorax was 48.8% in
Kirkpatrick et al. considering CT scan as gold standard method in revealing OPTX [17].
• Like the previous Rowan KR et al. (13) study, Sartori et al. succeeded in elevating the
sensitivity of chest US in detection of pneumothorax to be 100% with overall
accuracy of 100% [18].
16] Zhang M, Liu ZH,Yang JX, et al. Rapid detection of pneumothorax by ultrasonography in patients with multiple trauma. Crit Care 2006;10(4):R112e9.
[17] Kirkpatrick AW, Sustic A, Blaivas M. Introduction to the use of ultrasound in critical care medicine. Crit Care Med 2007;35(5):S123e5.
[18] Sartori S, Tombesi P, Trevisani L, et al. Accuracy of transthoracic sonography in detection of pneumothorax after sonographically guided lung biopsy:
prospective comparison with chest radiography. Am J Roentgenol 2007;188(1):37e41.
 DISCUSSION

• Investigating the usage of chest US in 204 polytraumatized patients, Nandipati et

al., 2011 declared an accuracy of 99% in showing pneumothorax [20].
• But in 2012, Hyacinthe et al. reported lower sensitivity 53% of chest US in detection of
pneumothorax but with still high specificity approaching 96% [21].
• Absence of lung sliding was the most sensitive ultrasonographic sign to
diagnose OPTX in this study with 96.77% sensitivity, 93.75% positive predictive value
and 92.5% accuracy.
[20] Nandipati KC, Allamaneni S, Kakarla R, et al. Extended focused assessment with sonography for trauma (EFAST) in the diagnosis of pneumothorax:
experience at a community based level I trauma center. Injury 2011;42(5):511e4.
[21] Hyacinthe AC, Broux C, Francony G, et al. Diagnostic accuracy of ultrasonography in the acute assessment of common thoracic lesions after trauma.
Chest 2012;141(5):1177e83.
DISCUSSION

• On the other hand, presence of lung point was the most specific 100% ultrasound
sign in detection of OPTX with less sensitivity and accuracy (70.97% and 77.5%
respectively).
• Absence of B lines (comet tail) had an accuracy of 90% in detection of an OPTX with
90.32% sensitivity and 88.89% specificity.
 DISCUSSION

• While Dulchavsky et al. [12] reported absence of lung sliding as the most specific
(100%) ultrasonographic feature of pneumothorax, Lichtenstein et al. [22] described
absence of lung sliding as the most sensitive one reaching up to 100%. Chan [23] clarified
that absent B lines was the most sensitive (100%) chest US reading of OPTX.
• Both of them Lichtenstein et al. [22] and Chan [23] gathered to confirm the
specificity of lung point in revealing OPTX.

[12] Dulchavsky SA, Schwarz KL, Kirkpatrick AW, et al. Prospective evaluation of thoracic ultrasound in the detection of pneumothorax. J
Trauma Acute
Care Surgery 2001;50(2):201e5.
[22] Lichtenstein DA, Meziere G, Lascols N, et al. Ultrasound diagnosis of occult pneumothorax. Crit Care Med 2005;33(6):1231e8.
[23] Chan SS. Emergency bedside ultrasound to detect pneumothorax. Acad Emerg Med 2003;10(1):91e4.
 CONCLUSIONS

Bedside thoracic ultrasonography is a simple, rapid and

reliable tool with high sensitivity, specificity and accuracy that
can be dependable for diagnosis of occult pneumothorax in
chest trauma patients.