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Current management of moderate to severe traumatic pneumothoraces: a survey of emergency clinicians
  1. Pascale Avery1,
  2. Millie Watkins2,
  3. Jonathan Benger3,
  4. Edward Carlton1
  1. 1Emergency Department, Southmead Hospital, North Bristol NHS Trust, Westbury on Trym, Bristol, UK
  2. 2Medical School, University of Bristol Faculty of Medicine and Dentistry, Bristol, UK
  3. 3Faculty of Health and Life Sciences, University of the West of England, Bristol, UK
  1. Correspondence to Pascale Avery, Emergency Department, Southmead Hospital, North Bristol NHS Trust, Westbury on Trym, Bristol, BS10 5NB, UK; pascale.avery{at}nhs.net

Abstract

Background Traumatic pneumothoraces are present in one-fifth of multiple trauma victims. Traditional teaching mandates the insertion of a chest drain in the majority of cases. However, recent observational evidence suggests a trend towards conservative management. The aim of this survey was to understand current emergency medicine (EM) practice in placing chest drains for the management of moderate to severe traumatic pneumothoraces.

Methodology The survey was developed through expert consensus and sent electronically to senior EM doctors in 21 sites internationally. It described six clinical/imaging vignettes asking ‘how likely are you to insert an intercostal chest drain to manage the pneumothorax in ED?’. A five-point response was available from very unlikely to very likely. All pneumothoraces were >1 cm on imaging, but mechanism, physiology and need for ventilation varied.

Results Of a potential 606 respondents, 222 responses were received (37% response rate). Respondents were from five different countries, with the majority qualified for more than 10 years (median; 18 years). Within each scenario, there was a large variation in responses with the exception of tension pneumothorax. For vignettes without tension pneumothorax, there was a range from 52% (non-compromised 1 cm pneumothorax in a ventilated patient) to 89% (open pneumothorax with minimal clinical compromise) in respondents reporting that they would be likely or very likely to insert a chest drain.

Conclusion There is considerable variation in clinical practice involving both conservative and invasive strategies in the treatment of moderate to severe traumatic pneumothoraces. This suggests clinical equipoise for interventional trials to determine the optimal management strategy for this patient group.

  • trauma
  • chest
  • pneumothorax
  • management
  • emergency department management

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Footnotes

  • Handling editor Richard Body

  • Contributors EC and JB conceived the idea for the study. All authors were responsible for collating and interpreting results. All authors critically revised successive drafts of the manuscript and approved the final version.

  • Funding This work was undertaken during an National Institute of Health Research Advanced Fellowship (Carlton) to inform trial design for a grant application. Benger is an NIHR Senior Investigator.

  • Competing interests None declared.

  • Patient and public involvement statement It was not appropriate or possible to involve patients or the public in the design, or conduct, or reporting or dissemination plans of this survey.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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