Occult pneumothorax in trauma patients: development of an objective scoring system

The incidence of occult pneumothorax (OPTX) has dramatically increased since the widespread use of computed tomography (CT) scanning. The OPTX is defined as a pneumothorax not identified on plain chest X-ray but detected by CT scan. The overall reported incidence is about 5% to 8% of all trauma patients. We conducted a 5-year review of our OPTX incidence and asked if an objective score could be developed to better quantify the OPTX. This in turn may guide the practitioner with the decision to observe these patients.

This is a retrospective review of all trauma patients in a Level I university trauma center during a 5-year period. The patients were identified by a query of all pneumothoraces in our trauma registry. Those X-ray results were then reviewed to identify those who had OPTX. After developing an OPTX score on a small number, we retrospectively scored 50 of the OPTXs by taking the largest perpendicular distance in millimeters from the chest wall of the largest air pocket. We then added 10 or 20 to this if the OPTX was either anterior/posterior or lateral, respectively.

A total of 21,193 trauma patients were evaluated and 1,295 patients with pneumothoraces (6.1%) were identified. Of the 1,295 patients with pneumothoraces, 379 (29.5%) OPTXs were identified. The overall incidence of OPTX was 1.8%: 95.7% occurred after blunt trauma, 222 (59%) of the OPTX patients had chest tubes and of the remaining 157 without chest tubes, 27 (17%) were on positive pressure ventilation. Of the 50 studies selected for scoring, the average score was 28.5. The average score for those with chest tubes was 34. The average score for those without chest tubes was 21. The positive predictive value for need of chest tube if the score was >30 was 78% and the negative predictive value if the score was <20 was 70%. Area under the receiver operator characteristic curve was 0.72, which was significant with p < 0.007.

The OPTX score could quantify the size of the OPTX allowing the practitioner to better define a "small" pneumothorax. The management of OPTX is not standardized and further study using a more objective classification may assist the surgeon's decision-making. The application of a scoring system may also decrease unnecessary insertion of chest tubes for small OPTXs and is currently being prospectively validated.