CHAPTER 56

#### KEY POINTS

• Pneumothorax in critically ill patients is often missed with conventional chest radiography. Ultrasound is a more reliable means of detecting pneumothorax.

• Pleural effusions can be detected by chest radiograph, chest CT and ultrasound. Ultrasound can be used for real time guidance of thoracentesis and chest tube placement.

• Empyema is the presence of pus within the pleural space and should be treated with systemic antibiotics as well as insertion of a chest drain. Other relative indications for placement of a chest drain include: positive gram stain or culture of pleural fluid and/or pH <7.2.

• Recurring pleural effusions (eg, malignancy) can be managed by placement of a tunneled drainage system or pleurodesis (chemical or surgical).

• Pleurodesis is extremely painful and should always be preceded by aggressive anesthesia and analgesia.

• Chest tubes placed for pneumothorax should be evaluated daily for air leak. Pleural drainage systems can usually be placed on water seal rather than suction. This may hasten the resolution of leak across the visceral pleura and thus hasten chest tube removal.

• Chest tube removal can be considered when there is no air leak in the pleural drainage system (pneumothorax) and/or there is less than 100 to 300 mL of fluid drainage per day (effusion).

#### INDICATIONS FOR THORACOSTOMY

Thoracostomy tubes, alternatively called chest drains, are inserted to drain fluid or air from the pleural space and remain in place until the drainage is completed. The indications for thoracostomy placement differ based on the amount of air, characteristics of the fluid as well as the clinical and physiologic consequences of these pleural space collections.

##### PNEUMOTHORAX

A pneumothorax is defined as a collection of air within the pleural space. Often pneumothoraces can occur in otherwise healthy people (ie, primary spontaneous pneumothorax), but can also be postsurgical, iatrogenic, or related to trauma, including barotrauma from ventilator-induced lung injury. Secondary pneumothoraces occur in the setting of underlying lung disease. Symptoms of either a primary or secondary pneumothorax can include pleuritic chest pain or dyspnea; however, patients with secondary pneumothorax often have shortness of breath that is out of proportion to the size of the pneumothorax.31,32 Physical exam findings can be subtle, but can range from tachypnea and tachycardia to hypotension and cardiovascular collapse. Tracheal deviation away from the side of the pneumothorax and decreased breath sounds on the affected side as well as subcutaneous emphysema may be present.

Imaging studies can be helpful in establishing a diagnosis. Chest computed tomography is the gold standard for diagnosis of pneumothorax. Indeed, nearly 40% of traumatic pneumothoraces are not clinically apparent.1 Chest roentography is a common method of identifying a pneumothorax once it is suspected clinically. Fully upright posteroanterior and lateral films are the most accurate roentographic method to identify a pneumothorax, although these are sometimes challenging to obtain, particularly in critically ill patients. A pneumothorax is identified by the presence ...

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