Are Occult Pneumothoraces Truly Occult or Simply Missed?

Abstract

Less than 24% of all OPTXs might have been inferred from subtle radiologic findings, such as the deep sulcus sign. The majority of OPTX cases (50-64%) did not warrant a CT scan based on other findings. Concern for an OPTX after severe trauma is a valid indication for thoracic CT.

Evaluation of a thoracic focused assessment with sonography for trauma (TFAST) protocol to detect pneumothorax and concurrent thoracic injury in 145 traumatized dogs

“…9 However, CXR in humans increases risk of clinical deterioration in traumatized and intensive care patients, involves radiation exposure, incurs delay in diagnosis, and is prone to misinterpretation. [14][15][16]18,[19][20][21] In traumatized dogs and cats, CXR poses similar concerns. Transport to the radiology area, requiring physical movement and restraint of the patient, increases stress and oxygen demand, potentially compromising critically injured dogs and cats.…”

“…[1][2][3][4]14,[16][17][18]27,28,[31][32][33][34][35] Using computerized tomography (CT) as the gold standard, reports have documented the reliability of thoracic US to diagnose PTX in humans. 1,16,18,19,27 Moreover, human studies have shown thoracic US to be comparable in specificity (94% versus 100%) and superior in sensitivity (88-100% versus 36%-75%) to supine survey CXR, 1,15,16,27,[36][37][38][39][40] with CXR missing 30-50% of radiographically occult pneumothoraces. [14][15][16][17]40 US has been dubbed an 'extension of the physical exam' regarding intrathoracic fluid, in human critical care and trauma settings, because of its high sensitivity and specificity in detecting pleural and pericardial fluid compared with physical examination and CXR findings.…”

“…1,16,18,19,27 Moreover, human studies have shown thoracic US to be comparable in specificity (94% versus 100%) and superior in sensitivity (88-100% versus 36%-75%) to supine survey CXR, 1,15,16,27,[36][37][38][39][40] with CXR missing 30-50% of radiographically occult pneumothoraces. [14][15][16][17]40 US has been dubbed an 'extension of the physical exam' regarding intrathoracic fluid, in human critical care and trauma settings, because of its high sensitivity and specificity in detecting pleural and pericardial fluid compared with physical examination and CXR findings. 35,41,42 Historically, the problems air poses during US have been incorrectly presumed to be insurmountable obstacles by most clinicians, since US is not transmitted through air.…”

“…[11][12][13] Historically, PTX has been diagnosed in humans based on clinical suspicion, physical examination, and chest radiography (CXR), but with inconsistent reliability. [14][15][16][17][18] In small animal veterinary patients, physical examination has been likewise unreliable, and thoracic radiography is considered the mainstay for the diagnosis of PTX and other thoracic trauma. 9 However, CXR in humans increases risk of clinical deterioration in traumatized and intensive care patients, involves radiation exposure, incurs delay in diagnosis, and is prone to misinterpretation.…”

Critical Care Issues in the Early Management of Severe Trauma

“…The reasons associated with delayed diagnosis have been investigated, and include trauma severity, conditions that alter the process of attention, conditions that complicate the clinical evaluation, and errors in the process (Box 3) [147,152,154,163,164].…”