Background • Pleural ultrasonography (PU) is more sensitive than chest radiograph (CXR) for diagnosing pneumothorax and could be useful for detecting resolution of pneumothorax after drainage. The aim of this prospective double- blind observational study was to assess PU accuracy during pneumothorax follow-up after drainage. Metode • All patients hospitalized with pneumothorax requiring drainage were eligible. After drainage, residual pneumothorax was assessed by CXR and PU – 24 h after bubbling in the aspiration device had stopped, – 6 h after clamping the pleural catheter, and – 6 h after removing the pleural catheter. Pneumothorax indicated by PU but not CXR was confirmed by CT scan or by aspiration of 10 mL of air. Results • Forty-four unilateral pneumothoraces were studied (primary spontaneous: 70.5%), and 162 pairs of examinations (CXR and PU) were performed. Twenty residual pneumothoraces were detected by both CXR and PU. Furthermore, PU suspected 14 pneumothoraces that were not identified by CXR; 13 were confirmed. All of these pneumothoraces resulted in therapeutic intervention. • Thus, 39% (13/33) of the confirmed residual pneumothoraces were missed by CXR. In patients with primary spontaneous pneumothorax, the positive predictive value of PU for residual pneumothorax diagnosis was 100%; for other pneumothoraces, this value ranged from 90% in the absence of a lung point to 100% when a lung point was observed. PU results were obtained faster than results from CXR (35 34 min vs 71 56 min, P <0001). Conclusions • The accuracy of PU is excellent for detecting residual pneumothorax during pneumothorax follow-up after drainage.
CHEST 2010; 138(3):648–655
• Chest CT scan is the most accurate way to diagnose pneumothorax, Conversely, chest radiographs (CXR) miss 30% to 72% of pneumothoraces because of their anterior location. However, half of these can be with tension. • Most physicians perform CXR several hours after stopping the suction device before removing chest tube. • Despite these precautions, pneumothorax frequently recurs after clamping or removing the chest tube. Some of these may be due to residual pneumothorax present before clamping or removing the chest tube but missed by CXR. • Lichtenstein et al reported that PU detects all pneumothoraces in ICU patients, including those not identified by CXR • Thus, use of PU rather than CXR for detecting residual pneumothorax after drainage could detect more pneumothorax recurrences, save time, and decrease costs and radiation exposure • The purpose of this study was to evaluate PU accuracy in diagnosing residual pneumothorax after chest tube insertion. • November 2007 and May 2009 four-bed intermediate care unit that houses all patients with pneumothorax requiring drainage in our tertiary teaching hospital. • Exclusion criteria were as follows: – (1) the absence of visualization of the pleural line on PU because of subcutaneous emphysema, – (2) use of mechanical ventilation because of decreased PU specificity. Design • End points included the following: – (1) the number of residual pneumothoraces diagnosed by PU, including those not identified by CXR; – (2) the therapeutic impact of PU use; – (3) the time to obtain CXR and PU results; – (4) the residents learning curve for using PU. • The success rate for primary spontaneous pneumothorax is generally better than for other types of pneumothorax. Thus, pneumothoraces were analyzed according to their cause. Drainage • All pneumothoraces were drained using a dedicated device, Pleurocath 8 French (Plastimed division, Prodimed; St-Leu-la- Forêt, France), that was connected to a one-bottle water seal vacuum system regulated to generate a depressurization of 30 cm H 2 O. Nurses assessed pleural catheter patency every 4 h using 5 mL of saline and noted whether bubbles were present in the aspiration device (patients were asked to cough if necessary) • Ultrasound diagnosis of pneumothorax relies on three signs: – abolition of lung sliding, the A-line sign, and the lung point. Before drainage, sensitivity and specifi city of the abolition of lung sliding are 100% and 91%, respectively
• The A-line sign is defined as the presence of A-
lines without B-lines • Before drainage, the sensitivity of the A-line sign is 100%, and its specifcity is 60%. The presence of B-lines rules out pneumothorax diagnosis. • The lung point is detected while the probe is stationary: there is lung sliding during inspiration (when the lung contacts the wall) that disappears during expiration (when the lung is not in contact with the wall). Before drainage, its sensitivity for diagnosis of pneumothorax is 66%; sensitivity increases to 79% for pneumothoraces missed by CXR, 13 whereas its specificity is 100% ( A ) Assessment of lung sliding on PU in two- dimensional mode. The pleural line is seen between two ribs. Lung sliding is abolished when both the parietal and visceral pleura do not slide while the patient is breathing. B ) Assessment of lung sliding on PU in time-motion mode on a patient without pneumothorax. Lung sliding generates a granular pattern under the pleural line. Subcutaneous tissue over the pleural line does not move while the patient is breathing, generating horizontal lines C ) Detection of abolition of lung sliding on PU in time- motion mode in a patient with pneumothorax. While the patient is breathing, the (normal) granular pattern under the pleural line is replaced by horizontal lines, indicating abolition of lung sliding. A ) The presence of vertical linear artifacts arising from the pleural line (B-lines or comet-tail artifacts) rules out pneumothorax in this patient with interstitial syndrome. B ) The A-line sign: The presence of linear horizontal artifacts at regular intervals below the pleural line (A-lines) without B-lines. The A-line sign is part of the ultrasound semiology of the normal lung and pneumothorax. The Learning Curve for PU Detection of Pneumothorax • Each PU was also performed by one of the ICU residents, who received 2 h of training that focused on ultrasonographic diagnosis of pneumothorax. Statistics • The Student t test was used to compare how long it took to obtain results from CXR vs PU. • Lung point incidence for pneumothoraces (whether apparent on CXR or not) was compared using Fisher exact test. • The residents’ learning curve was determined by comparing the PU results (% agreement) obtained by the residents and the primary investigator. The diagnostic agreement between the primary investigator and the residents was assessed by the k coefficient Results • Fifty-one patients admitted between November 2007 and May 2009 had pneumothorax requiring drainage. Five patients were excluded because they were on mechanical ventilation, and two were excluded because of important subcutaneous emphysema that impaired pleural line visualization on PU. The final analysis included 44 patients with unilateral pneumothorax (mean age, 37.5 15.0 years; men, n =31 [70.5%]). • Pneumothorax cause was as follows: primary spontaneous (n=31, 70.5%), traumatic (n=7, 15.9%), secondary to pulmonary emphysema (n=4, 9.1%), and iatrogenic after placement of a central venous catheter (n=2, 4.5%). • Thirty-seven patients were treated successfully by pleural catheter, whereas seven patients (15.9%) required surgical treatment. Detection of Residual Pneumothorax • A total of 162 CXR and PU examinations were performed during the follow-up of 44 pneumothoraces. CXRs revealed 20 residual pneumothoraces in 14 patients; all 20 were also detected by PU. Furthermore, PU identified 14 suspected pneumothoraces that were missed by CXR, and and 13 of these were confirmed in nine patients by CT scan (n =5) or air aspiration (n=8). • During follow-up of the 31 primary spontaneous pneumothoraces, 117 CXR and PU examinations were performed. The eight pneumothoraces suspected by PU but not identified by CXR were all confirmed (six by air aspiration, two by CT scan). • The PPV of PU for diagnosing residual pneumothorax after drainage of primary spontaneous pneumothorax was 100%. Time to Obtain CXR and PU Results • Results of PU were obtained after 35 34 min whereas results of CXR were obtained after 71 56 min. • This difference was signifi cant ( P <0.001). DISCUSSION • This is the first study to our knowledge to show that PU is better than CXR for detecting residual pneumothoraces after drainage and that 39% of them were not identified by CXR. PU are obtained more rapidly than results of CXR. the learning curve showed that naïve residents were able to perform reliable PU after 2 h of training. • The lung point is an inconstant sign, but has a specificity of 100% for pneumothorax diagnosis. The fact that the PPV of PU was still perfect (100%) . • suggests that PU should be used instead of CXR to assess the resolution of primary spontaneous pneumothoraces. • Like every ultrasound examination, the quality of PU examination results depends to some extent on the person conducting the examination. The learning curve of ICU residents in this study showed that the residents’ results were reliable after 2 h of training. These results confirm that for PU, as for echocardiography 41 and general ultrasonography, 42 training for nonradiologist physicians is simple and does not take a long time. Conclusions • This study showed that PU diagnostic performance was excellent for pneumothorax follow-up after drainage. PU offered several advantages over CXR, PU diagnosed all residual pneumothoraces, many of which were not identified by CXR; PU led to extra therapeutic interventions; PU gave faster results than CXR; and PU was performed competently by naïve physicians after a brief (2-h) training session.