Basic Ultrasound Training Can Replace Chest

Radiography for Safe Tube Thoracostomy Removal

KEDAR S. LAVINGIA, M.D., MICHAEL C. SOULT, M.D., JAY N. COLLINS, M.D., TIMOTHY J. NOVOSEL, M.D.,
LEONARD J. WEIRETER, M.D., L. D. BRITT, M.D., M.P.H.

From the Department of Surgery, Eastern Virginia Medical School, Norfolk, Virginia

An ultrasound (US) examination can be easily and rapidly performed at the bedside to aide in
clinical decisions. Previously we demonstrated that US was safe and as effective as a chest x-ray
(CXR) for removal of tube thoracostomy (TT) when performed by experienced sonographers. This
study sought to examine if US was as safe and accurate for the evaluation of pneumothorax (PTX)
associated with TT removal after basic US training. Patients included had TT managed by the
surgical team between October 2012 and May 2013. Bedside US was performed by a variety of
members of the trauma team before and after removal. All residents received, at minimum,
a 1-hour formal training class in the use of ultrasound. Data were collected from the electronic
medical records. We evaluated 61 TTs in 61 patients during the study period. Exclusion of 12 tubes
occurred secondary to having incomplete imaging, charting, or death before having TT removed.
Of the 49 remaining TT, all were managed with US imaging. Average age of the patients was 40
years and 30 (61%) were male. TT was placed for PTX in 37 (76%), hemothorax in seven (14%),
hemopneumothorax in four (8%), or a pleural effusion in one (2%). Two post pull PTXs were
correctly identified by residents using US. This was confirmed on CXR with appropriate changes
made. US was able to successfully predict the safe TT removal and patient discharge at all resi-
dency levels after receiving a basic US training program.

thoracostomy (TT) is common is an effective method for the management of TT

T HE NEED FOR TUBE
after blunt or penetrating trauma. Often this will
be the only surgical intervention required. The best
practice for TT removal has been variable with mul-
tiple algorithms proposed in the current trauma liter-
ature.1 The mainstay of TT removal and assessment of
resolution of a pneumothorax (PTX) is through the use
of chest x-ray (CXR).13 Unfortunately, portable
CXRs are notoriously poor for the evaluation of apical
and small-sized PTXs and a significant number of
PTXs are missed.47 Computed tomography (CT) re-
mains the gold standard for the diagnosis of PTX, yet
its high cost and required patient transport render it
impractical for routine daily use for the evaluation
of PTX when compared with a portable CXR.4, 811
The TT removal technique is largely dictated by prior
training and the preference of the attending physician
or individual institutional guidelines. Our own data at
this institution have demonstrated that ultrasonography,
when conducted by experienced surgeon sonographers,
Presented at the Annual Scientific Meeting and Postgraduate
Course Program, Southeastern Surgical Congress, Savannah, GA,
February 2225, 2014.
Address correspondence and reprint requests to Jay N. Collins,
M.D. 825 Fairfax Avenue, Hofheimer Hall, Suite 610, Norfolk,
VA 23507. E-mail: collinjn@evms.edu.
removal.12
In this era of optimal resource use, current goals are
to shorten hospital stay, decrease cost, and reduce ion-
izing radiation exposure without compromising patient
care. The goal of this study was to examine if residents
at any level of training can use ultrasonography safely
and effectively in the management of TT removal for
trauma patients after a basic ultrasound (US) training
course.
Methods
This is a retrospectively reviewed study conducted at
Sentara Norfolk General Hospital, the regional Level I
trauma center, in conjunction with the Eastern Virginia
Medical School (EVMS) Department of Surgery. All
patients who were 18 years old or older and had a TT
managed by the MultiTrauma Service (MTS) between
October 2012 and May 2013 were considered for study
inclusion. All residents involved in the study period
had received a prior basic US course before starting
their MTS rotation. The course included, but was not
limited to, the basic principles of US imaging and the
anatomy of the axial, longitudinal, and corona1 planes
examined in US scanning with special emphasis on the
sectional anatomy of the chest, abdomen, and pelvis.

783
784 THE AMERICAN SURGEON August 2014 Vol. 80

The course also included a review of the major clinical
indications and applications of US in diagnosis and
treatment of multiply injured patients. Multiple posi-
tive images were included that were relevant to sur-
gical training. These included but were not limited to
free fluid in the abdomen, pericardial fluid, and absence
of lung slide.
The decision algorithm for removal of a TT was that
a candidate patient had their TT placed to waterseal at
midnight. Before removal of TT, an US examination of
the thoracic cavity was performed, approximately six
to eight hours after placement to waterseal, at the bed-
side by a resident member of the trauma service. The
thoracic cavity was evaluated using a linear L25x 13-6
MHz probe (M-Turbo; SonoSite, Bothell, WA) in both
B and M modes. Lung windows were observed in the
midclavicular line in the first three rib interspaces. A
clinically significant PTX was defined as the absence of
slide in all three lung windows on US or greater than
20 per cent of the thoracic cavity on CXR. Lung slide
was determined by the presence of the sliding pleura
against the chest wall, the comet-tail artifact, and the
seashore sign, which is the granular appearance of the
static lung against the moving chest wall in M mode1315
(Fig. 1). If adequate lung slide was witnessed by the
resident at all three sites, the TT was removed and
a dressing was placed over the prior TT site. Repeat US
examination was then performed two to four hours after
removal. If the US lacked pleural slide in any of the
three lung windows, a CXR for further imaging was
obtained. If no clinically significant PTX was identified
on US or CXR, patients were discharged home or
transferred to the next level of care.
Charts were reviewed for patient age, sex, indication
for TT, days the TT was in place, size of TT, and im-
aging results. Mean and standard deviation were cal-
culated for continuous variables. Categorical variables
were described as a fraction and percentage. Com-
parison of each imaging modality was made using
FIG. 1. Ultrasound evaluation for pneumothorax (PTX): (A) the
probe location used during thoracic ultrasound evaluation for PTX.
(B) Normal lung with pleural surface (large arrow) and comet tails
(small arrows), which are caused when the pleural surfaces are
rubbing against one another.
TABLE 1. Patient Demographics and Indications for Tube
Thoracostomy Placement
Total
Variable (49 TT)
Age (years) 40 22
Male 30 (61%)
Race
Black 35 (71%)
White 10 (21%)
Other 4 (8%)
Body mass index (kg/m2) 19 9
Indications for TT
PTX 30 (61%)
Hemothorax 16 (33%)
Hemopneumothorax 3 (6%)
TT, tube thoracostomy; PTX, pneumothorax.
sensitivity, specificity, negative predictive value (NPV),
and positive predictive value (PPV). Data analysis was
performed with the use of SPSS statistical analysis
software (SPSS Inc., Chicago, IL). The Institutional
Review Board at EVMS approved the study and waiver
of consent was provided for review of patient data.
Results
Patients
Sixty-one TTs placed in 61 patients were identified
that were managed by the MTS in the given time pe-
riod. Exclusion of 12 tubes occurred secondary to hav-
ing incomplete imaging, charting, or death before having
TT removed. The average age of the patients was
40 years old (range, 18 to 94 years); 30 patients (61%)
were male and 19 (39%) were female. A blunt injury
occurred in 26 (53%) patients and a penetrating injury in
23 (47%) patients. Indications for TT placement included
PTX in 30 (61%) patients, a hemothorax in 16 (33%)
patients, and hemopneumothorax in three (6%) (Table 1).
Before Tube Thoracostomy Removal
All 49 patients had complete waterseal pre and post
pull US examinations. Forty-three patients had tubes
placed with tube size ranging from 24 to 36 Fr (mean,
30 Fr), and six (12%) patients had small-bore 9-Fr
chest tubes placed. The mean number of days that the
TT remained in place was 2.5 1.2. Resident level
ranged from Postgraduate Year (PGY)-1 to PGY-4.
Twenty-five TTs were removed by PGY-2 residents.
PGY-1 level residents were responsible for removal of
14 TTs. The remaining 10 were removed by senior-
level residents (PGY-3 to PGY-4). Ultrasound exami-
nation showed no evidence of a clinically significant
PTX in all 49 TTs on waterseal. All patients had
subsequent removal of the TT at bedside.
No. 8 ULTRASOUND TRAINING REPLACES CHEST RADIOGRAPHY
Posttube Thoracostomy Removal
Post-pull examination was conducted at a mean of
two hours postremoval of TT (range, 30 minutes to 4
hours). The level of resident training was similar with
junior residents (PGY-1 to PGY-2) conducting 38 of
the US examinations. Five patients were found not to
have adequate lung slide on US testing and required
further imaging with a CXR. Of the five, two patients
had clinically insignificant PTX based on CXR and
US findings, required no intervention, and were dis-
charged. Two patients had a clinically significant PTX
confirmed on CXR and required repeat TT place-
ment. One patient had a recurrent hemothorax, which
required interventional radiology to place a drain. Of
the two patients with a clinically significant PTX seen
on CXR, both were detected with US by the junior
resident on the trauma service. Although calculation
of NPVs and PPVs are not valid given that we did not
obtain a CXR on all patients, we had no adverse
clinical outcomes when using US to predict TT re-
moval. Additionally, no patients were readmitted to
the hospital nor were we notified that a patient
returned to an outside hospital with a recurrent PTX
after tube removal during the study period. Overall,
all of the TTs were safely managed with US alone,
thus significantly reducing the number of CXRs re-
quired and allowing more rapid transition to the next
level of care.
Discussion
The management of TTs has been based on resolu-
tion of thoracic pathology seen on a CXR. A post-
removal CXR is required some two to six hours after
removal of a TT to evaluate for a recurrent PTX. The
CXR is limited by the availability of ancillary staff to
take the radiograph in a timely manner, upload the
images, and make them available for interpretation.
Because a CXR only provides an isolated, static image
of the thoracic cavity and has been shown to miss
a PTX in 15 to 30 per cent of patients,1618 a readily
available, highly reliable alternative is needed.19, 20
Routine CXR use adds to the in-hospital time for pa-
tients while exposing them to unnecessary radiation
and cost. Although CT remains the gold standard for
the evaluation of the thoracic cavity, the cost, radiation,
and logistics required to obtain the study make it im-
practical for daily use in the management of TTs.8
Kwan et al. demonstrated that US can be used to
determine that a PTX has resolved after TT removal
with a NPV of 91 per cent. He argues that US is useful
in the decision to remove a TT. The study is small but
demonstrates the use of an easy-to-use, easy-to-repeat
bedside test that has very good reliability.21, 22
? Lavingia et al. 785
Thoracic US uses a dynamic evaluation of the tho-
racic cavity rather than the static image provided by
a CXR. Combining the portability of US with the
elimination of ionizing radiation, thoracic US allows
for timely and rapidly reproducible information re-
garding the presence or absence of a PTX.12 Prior
work at our institution has demonstrated that US has
the ability to detect a clinically significant PTX with
a NPV of 100 per cent.12 The use of US allowed pa-
tients with normal lung slide on US examination to
have their TT removed and be discharged to the next
level of care faster than with the use of CXR and re-
duce the number of radiographs the patient required
after TT placement. These findings were based on
interpretation of US images by two experienced sur-
geon sonographers. After we established that US has
a NPV of 100 per cent, this current study shows that
similar clinical results can be obtained with any level
resident after a basic US training course. This was
confirmed with the fact that we had no adverse clinical
outcomes in our study group. This course is now a part
of the PGY-1 orientation at our institution.
There are limitations to the US examination for
a PTX. Factors such as subcutaneous air, bleb disease
from emphysema, extensive decortication/pleurodesis,
or morbid obesity (body mass index greater than 40 kg/
m2) can affect an US examination. Such patients may
have a loss of pleural slide and represent false-positive
findings.23 These findings mandate a confirmatory
CXR for any thoracic US concerning for the presence
of a PTX before making further clinical decisions.
However, junior resident evaluation was accurate in
the diagnosis of a PTX in the two patients who initially
had a normal US on waterseal but developed a post pull
PTX. This suggests that US would be adequate for
intervention if the initial examination demonstrated
pleural slide and is not concerning for a PTX.
There are a few limitations to our study. This is
a retrospective study with low power and from a single
institution. Furthermore, it is possible that a patient
potentially sustained a complication after discharge
after TT removal because detailed follow-up was not
obtained in all patients. However, we are not aware of
any readmissions to other facilities outside of our in-
stitution. After a brief US educational course taught at
EVMS, users at various stages of training and physi-
cian extenders have rapidly implemented the use of US
for TT management after our prior studies demon-
strated that US examination is safe and an effective
method for TT management. The key element in ed-
ucating novice users is to identify the presence of
a PTX during an evaluation. Once a positive US ex-
amination is seen by a trainee, it becomes easier to
detect on future examinations. Once the junior resident
has demonstrated the ability to adequately detect
786 THE AMERICAN SURGEON
abnormal pathology, a user is allowed to perform in-
dependent thoracic examinations for PTX. Since
completion of this study, US for TT removal has
remained the procedure of choice at EVMS and has
been used by multiple users of various US experience
without any complications to date.
Conclusion
After receiving a basic US training course, US was
able to successfully predict safe TT removal and dis-
charge post pull, regardless of the training level of the
residents. Ultrasound examination allows for timely
TT removal, reduced patient exposure to radiation, and
helped reduce costs during hospitalization. We are
routinely using US for this evaluation and removal of
TTs.
REFERENCES
1. Martino K, Merrit S, Boyakye K, et al. Prospective ran-
domized trial of thoracostomy removal algorithms. J Trauma 1999;
46:36971.
2. Pacanowski JP, Waack ML, Daley BJ, et al. Is routine
roentgenography needed after closed tube thoracostomy removal?
J Trauma 2000;48:6848.
3. Adrales G, Huynh T, Broering B, et al. A thoracostomy tube
guideline improves management efficiency in trauma patients.
J Trauma 2002;52:2104; discussion 2146.
4. Rowan KR, Kirkpatrick AW, Liu D, et al. Traumatic pneu-
mothorax detection with thoracic US: correlation with chest radi-
ography and CTinitial experience. Radiology 2002;225:2104.
5. Ball CG, Hameed SM, Evans D, et al. Occult pneumothorax
in the mechanically ventilated trauma patient. Can J Surg 2003;46:
3739.
6. Kirkpatrick AW, Sirois M, Laupland KB, et al. Hand-held
thoracic sonography for detecting post-traumatic pneumothoraces:
the Extended Focused Assessment With Sonography For Trauma
(EFAST). J Trauma Inj Infect Crit Care 2004;57:28895.
7. Ball CG, Kirkpatrick AW, Laupland KB, et al. Factors related
to the failure of radiographic recognition of occult posttraumatic
pneumothoraces. Am J Surg 2005;189:5416; discussion 546.
8. Brenner DJ, Hall EJ. Computed tomographyan increasing
source of radiation exposure. N Engl J Med 2007;357:227784.
August 2014 Vol. 80
9. Nandipati KC, Allamaneni S, Kakarla R, et al. Extended
focused assessment with sonography for trauma (EFAST) in the
diagnosis of pneumothorax: experience at a community based level
I trauma center. Injury 2011;42:5114.
10. Diederich S, Lenzen H. Radiation exposure associated with
imaging of the chest: comparison of different radiographic and
computed tomography techniques. Cancer 2000;89:245760.
11. Wilkerson RG, Stone MB. Sensitivity of bedside ultrasound
and supine anteroposterior chest radiographs for the identification
of pneumothorax after blunt trauma. Acad Emerg Med 2010;17:
117.
12. Soult M, Collins J, Novosel T, et al. Thoracic ultrasound can
predict safe removal of thoracostomy tubes. Am J Respir Crit Care
Med 2013;187:A1535.
13. Lichtenstein D, Meziere G, Biderman P, et al. The comet-
tail artifact: an ultrasound sign ruling out pneumothorax. Intensive
Care Med 1999;25:3838.
14. Lichtenstein D, Meziere G, Biderman P, et al. The lung
point: an ultrasound sign specific to pneumothorax. Intensive Care
Med 2000;26:143440.
15. Lichtenstein DA, Meziere G, Lascols N, et al. Ultrasound
diagnosis of occult pneumothorax. Crit Care Med 2005;33:12318.
16. Lichtenstein DA, Menu Y. A bedside ultrasound sign ruling
out pneumothorax in the critically. III: Lung sliding. Chest 1995;
108:13458.
17. Saucier S, Motyka C, Killu K. Ultrasonography versus chest
radiography after chest tube removal for the detection of pneu-
mothorax. AACN Adv Crit Care 2010;21:348.
18. Verniquet A, Kakel R. The value of ultrasound in detecting
pneumothorax. Can J Anaesth 2011;58:118; author reply 1189.
19. Nagarsheth K, Kurek S. Ultrasound detection of pneumo-
thorax compared with chest X-ray and computed tomography scan.
Am Surg 2011;77:4804.
20. Ding W, Shen Y, Yang J, et al. Diagnosis of pneumothorax
by radiography and ultrasonography: a meta-analysis. Chest 2011;
140:85966.
21. Kwan RO, Miraflor E, Yeung L, et al. Bedside thoracic
ultrasonography of the fourth intercostal space reliably determines
safe removal of tube thoracostomy after traumatic injury. J Trauma
Acute Care Surg 2012;73:156873.
22. Chung MJ, Goo JM, Im JG, et al. Value of high-resolution
ultrasound in detecting a pneumothorax. Eur Radiol 2005;15:
9305.
23. Gillman LM, Alkadi A, Kirkpatrick AW. The pseudo-lung
point sign: all focal respiratory coupled alternating pleural patterns
are not diagnostic of a pneumothorax. J Trauma 2009;67:6723.
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