Occult traumatic pneumothorax: Is routine follow up chest X-ray necessary?

Occult pneumothoraces (OPTX) are pneumothoraces that are not seen on chest X-ray (CXR) but visualized on computerized tomography (CT) scan. OPTX are frequently discovered during the initial trauma evaluation, there is a paucity of evidence based guidelines on how they should be further monitored. In this study we hypothesized that the practice of obtaining routine CXR for the surveillance of OPTX does not alter clinical management.

We retrospectively analyzed all adult (18 years or older) patients with a traumatic (blunt and penetrating) OPTX over a 7-year period (2013-2019) evaluated at an academic, Level 1, urban trauma center. Patient demographics mechanism of injury were abstracted. We examined subsequent radiographic and clinical evolution of OPTX as well as the need for intervention.

363 patients were included in the series. Mean age was 47.8 years (range 18-98), 64.6% of the patients were male. Only 7 (1.9%) patients subsequently required an intervention for an OPTX. Neither age, sex, Injury severity score (ISS), or chest abbreviated injury score (AIS) (p = 0.072) were predictive of the need for intervention. Six of the seven patients that required intervention demonstrated clinical symptoms of pneumothorax progression.

In our experience the practice of obtaining routine chest X-rays for monitoring OPTX did not change clinical management. Obtaining a chest X-ray based on symptoms may be a more effective utilization of resources.