All patients who are being seen in consultation for a traumatic chest injury should have an appropriate overall trauma evaluation commensurate with the Advanced Trauma Life Support (ATLS) practices of the American College of Surgeons and in accordance with local institutional practices [12]. The traditional initial treatment for all symptomatic traumatic PTX has been, and for the most part remains, the placement of a large tube thoracostomy tube (32–36 French) in the fifth intercostal space at the anterior or mid-axillary line with the application of suction through a water seal drainage system [12]. Recently, however, there has been a trend to place smaller percutaneous tubes by the Seldinger technique in the second intercostal space at the anterior axillary line for the evacuation of smaller PTX. Though seemingly less traumatic, the use of these so-called pigtail catheters remains controversial. Small amounts of concurrent pleural blood, often unappreciated on semi-upright chest radiographs after injury, may clog these tubes. Fig. 15.2a shows a subtle left-sided HTX as visualized on the initial chest radiograph taken in the trauma bay. However, as seen in Fig. 15.2b, the patient had a sizeable posteriorly layering left HTX. Additionally, pigtail catheters do not have the diameter to evacuate large-volume air leaks and often require a second tube [15].

Patients who have hemodynamic or respiratory instability felt due to a tension PTX should have needle decompression of the pleural space using a 14 gauge 2-in. angiocatheter in the second intercostal space at the mid-clavicular line while preparations are made for thoracostomy tube placement. This is an immediate life-threatening condition and should be diagnosed on clinical grounds rather than radiographic findings as demonstrated in Fig. 15.1. Decompression will release positive pressure, allowing the mediastinum to return to midline and the patient to re-compensate. If the diagnosis of tension PTX was correctly made, the patient will improve in color and blood pressure almost immediately. A tube thoracostomy is then required as previously mentioned to treat the simple (non-tension) PTX thus created [12, 16].

Once the desired thoracostomy tube is placed, lung inflation should be confirmed by chest radiograph, preferably upright, and the amount of air leak, if any, should be noted. Failure of the lung to inflate with a large continuous air leak in the water seal chamber may indicate a tracheobronchial injury, which should be confirmed by bronchoscopy. If present, a second chest tube should be considered as the first maneuver. Thoracic specialty consultation should be obtained. The management of this injury is beyond the scope of this text. Failure of the lung to inflate without an air leak indicates mal-positioning of the tube, usually in the subcutaneous tissue or occlusion of the chest tube, drainage system, or bronchi. The system should be checked and bronchoscopy may be indicated. After placement of a thoracostomy tube, trauma patients treated for PTX should have a dynamic chest CT or CT angiogram contemplated to assess other latent thoracic injuries. It is well recognized that three thoracic injuries are identified on CT for every single injury noted on chest radiograph.

The increased sensitivity of CT scans will document occult PTX. Occult PTX is defined as a PTX noted only on CT scan but not evident on conventional chest radiograph [2, 17–20]. There is an increasing body of evidence and expert opinion that occult PTX are extremely unlikely to enlarge and can therefore be managed conservatively, as long as they remain stable in size and patients remain free of respiratory symptoms attributable to the PTX [13, 21]. Some have reported the successful deferral of thoracostomy even in the setting of positive pressure ventilation for surgical procedures [22]. However, the decision to defer thoracostomy should be approached cautiously in the multi-trauma patient. In this setting, an untreated PTX may create confusion when the patient suffers a hemodynamic or respiratory decompensation for unrelated reasons.

The spontaneous PTX due to congenital bleb in the young patient may be treated with a tube thoracostomy in the second interspace at the midclavicular line using a conventional tube or a pigtail catheter. The COPD patient with emphysematous bleb rupture may be treated similarly. However, in this situation a non-contrast chest CT should generally be obtained prior to tube placement (assuming that the patient is stable without evidence of tension physiology or respiratory compromise) to differentiate PTX from a giant emphysematous bleb [6–8, 23]. Placement of thoracostomy tubes into giant emphysematous blebs results in a bronchopleural fistula, which is very difficult to manage.

Small iatrogenic PTX due to attempted subclavian central venous catheter placement can generally be treated by observation or by placement of an apical pigtail catheter with good results since the site of injury is known to be at the apex. Larger iatrogenic PTX should receive conventional thoracostomy tubes placed in the apical position [24]. Table 15.1 presents pearls for thoracostomy tube placement.

Once the chest tube is in place and inflation of the lung is confirmed on radiograph, numerous protocols and guidelines exist for tube management [25]. In general, once the lung is inflated and pleural surfaces are brought into apposition, the air leak should cease. The thoracostomy tube is then left to suction for 24–48 h to allow pleural symphysis or sealing to occur. Time to sealing will vary with the magnitude of the air leak and the patient’s overall nutritional status. The removal of the tube from suction, known as placement on “water seal,” is generally used to confirm healing of the pleural leak. The water seal chamber on the drainage system is monitored for recurrence of an air leak, and if none is noted a confirmatory radiograph is done, typically from 3 to 8 h later. However, there is very little evidence supporting the duration of time necessary on water seal before a radiograph is performed [26]. If a recurrent leak is noted in the drainage system leak chamber, the system is placed back on suction and a radiograph is done to confirm that the lung remains inflated. Suction is continued another 24–48 h before reattempting water seal.

Importantly, the lung may remain inflated on water seal even when small air leaks are present since a route of egress for the air is available. Removal of the tube in this setting will lead to a recurrent PTX. Therefore, it is important to identify even small leaks in the leak chamber of the drainage system. This can be done by checking for air leaks during forced expiration by asking the patient to take deep breaths in and out and to cough. If a forced expiratory air leak is identified the chest tube should remain in place until completely resolved.

As noted previously, failure of the lung to inflate after tube thoracostomy with a large air leak should raise concern for tracheobronchial injury. However, persistent failure of small air leaks to seal despite inflated lung or recurrent PTX on water seal may present both a diagnostic and therapeutic challenge. A CT scan with the thoracostomy tube on suction should be done to identify uninflated areas of lung that may be contributing to a persistent air leak. Additional thoracostomy tubes or radiologically guided drainage catheters may be required. Video-assisted thoracoscopic surgery (VATS) for pleurodesis may ultimately be needed [27–30]. Surgical pleurodesis involves the application of various irritants to the pleural surfaces to cause inflammatory adhesion of the visceral and parietal pleura and thereby seal air leaks. There is some literature advocating very early VATS intervention in persistent air leak in trauma patients at 48 h post injury [31, 32]. As of this writing, any benefit of such an approach for PTX alone has not been definitively demonstrated. Figure 15.3 shows a general composite algorithm for the management of traumatic PTX.

Importantly, with spontaneous PTX due to ruptured congenital or emphysematous blebs, the lungs are inherently abnormal and sealing of the air leak may take longer than 48 h or may even fail to occur. When tube thoracostomy fails to seal a pleural leak in this clinical setting, surgical intervention, typically VATS with pleurodesis, is required.

The most common complication of PTX is respiratory failure. In the trauma setting, this is usually due to the combined effect of the loss of lung volume, pain, and splinting from associated rib fractures, burden of associated injuries, and any preexisting pulmonary conditions. Consequently, in addition to reinflating the lung, a thorough approach must be taken in ameliorating the concomitant causes of respiratory failure in the trauma patient. Failure of lung inflation is a rare complication of conservative management without thoracostomy. This usually does not occur unless there is associated pleural blood (HTX) causing an inflammatory response and resultant trapped lung (further described in the next section).

The main iatrogenic complications of thoracostomy placement include injury to almost any intrathoracic structure. This can be avoided by carefully palpating and exploring with the operating finger through the thoracostomy incision prior to placing the tube. Adhesions are swept away and placement above the diaphragm is ensured. Often chest tube placement introduces some degree of additional pain and immobility to patients which is not desirable. Consequently, the decision to place a tube should be carefully considered in cases of smaller PTX. Reasonable respiratory benefit should be expected as a trade-off for the potential increase in splinting due to the presence of the tube.

There is no evidence that patients who have had traumatic PTX inflated by a thoracostomy and show full inflation on “post-pull” radiograph several hours later need any further imaging as long as they remain clinically well. Nonetheless, it is the customary practice at many institutions to obtain a follow-up radiograph prior to discharge or at clinic visit. Patients who have been treated conservatively for small PTX generally receive a follow-up radiograph several weeks later to document full lung expansion, though the benefit of this also remains unclear. Recurrences are rare in otherwise healthy individuals in either situation. There is no standardized follow-up for patients with spontaneous PTX due to congenital bleb or emphysematous bleb rupture. These patients will generally become symptomatic if recurrences occur. They should maintain a close relationship with their pulmonologist or thoracic surgeon as recurrence rates may be as high as 50% [6–8].