Ultrasound may safely replace chest radiograph after tube thoracostomy removal in trauma patients

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.

A practice management guideline was established calling for the performance of a CXR and bedside US 2 h 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.

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.

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