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  • 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.

  • Indications for placement of a chest drain include: the presence of frank pus, positive gram stain or culture of pleural fluid and/or pH <7.2.

  • An empyema is the presence of pus within the pleural space and should be treated with systemic antibiotics, insertion of a chest drain and intrapleural tissue plasminogen activator (TPA) plus DNase.

  • Recurring pleural effusions (e.g. malignant) can be managed by placement of a tunneled drainage system which frequently results in spontaneous pleurodesis or patients can undergo directed pleurodesis (chemical or surgical).

  • Chemical and 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 the visceral pleural defect and subsequently stop the air leak, facilitating 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).



A pneumothorax is defined as a collection of air within the pleural space. Often pneumothoraces can occur in otherwise healthy people (i.e. 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 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.1–3 Physical exam findings can be subtle and may include decreased breath sounds on the affected side, subcutaneous emphysema, and/or tracheal deviation to the contralateral side. Alterations in vital signs can range from tachypnea and tachycardia to hypotension and cardiovascular collapse.

The sensitivity of physical exam to diagnose pneumothorax is unacceptably low, approximately 60%, and imaging studies can be helpful.4,5 Chest computed tomography is the gold standard for diagnosis of pneumothorax but is often not practical in critically ill patients. Chest radiography is a common method of identifying a pneumothorax once it is suspected clinically. Fully upright posteroanterior and lateral films are the most accurate method to identify a pneumothorax, although these are sometimes challenging to obtain, particularly in critically ill patients. A pneumothorax is identified by the presence of a dense white line with the absence of vascular markings lateral to it. At times, the patient’s positioning or lung pathology can cause an air ...

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