Management of Occult Pneumothoraces in Mechanically Ventilated Patients

NCT00530725 | Completed

• 1 other identifier: OPTICC Trial
• Study Type: interventional
• Target: 145
• Locations: 1 country
• Sites: 4

Brief Summary

Collapsed lungs are common injuries after traumatic injury that regularly cause needless deaths despite being treatable with chest tubes. Properly used these tubes can be life-saving. Unfortunately, improperly used they can cause pain, bleeding, and other fatal complications themselves. Over the last few decades with increased use of CT scanning it is apparent that many small collapsed lungs are not seen on chest X-rays, and there is little guidance for the treating Doctors as to how to treat these patients. There is almost no good data that tells us whether these smaller pneumothoraces require treatment with chest tubes or whether they can simply be closely watched. This proposal is to carry out a simple trial of randomly assigning patients who do not appear to have any symptoms or problems from their occult pneumothorax to either having a standard chest tube or to being watched. Our careful review of the medical literature indicates that the investigators cannot honestly tell patients and their families which treatment is best or required. Our audit of current practice also indicates that Doctors in Calgary and across Canada, regularly prescribe both treatments regularly but in a hap-hazard. The patients in this study will be very closely watched in the intensive care unit and if they develop any breathing problems and do not have a chest tube in, then one will be inserted. The main results that the investigators are trying to determine with this pilot study, though, is whether the investigators are able to detect appropriate patients, to recruit them into such a study, and whether the guidelines the investigators have created to manage these patients in this study will be acceptable to all the patient's care givers. This data will help us to design a future large multi-centre trial that will hopefully provide information as how best to manage this type of injured patient.

Conditions

Pneumothorax

Keywords

occult pneumothorax; mechanical ventilation; critical care; pneumothorax; thoracostomy

Outcome Measures

Primary Outcomes (1)

• Outcome Variables: In ventilated patients with small to moderate sized occult PTXs, the rate of respiratory distress will not differ between those treated with chest thoracostomy tubes and those not treated but simply observed

  admission to hospital discharge

Secondary Outcomes (1)

• Observation of small OPTXs in ventilated patients will not increases the rates of Emergency chest drainage, Death, tracheostomy, ARDS, Ventilator associated pneumonia (VAP), or the Abdominal Compartment Syndrome (ACS)

  admission to hospital discharge

Study Arms (2)

chest drainage

ACTIVE COMPARATOR

This represents the best current standard of care although this is quite controversial

Procedure: chest drainage

close observation

EXPERIMENTAL

This is the novel approach that has some justification in the literature

Other: close clinical observation

Interventions

chest drainage PROCEDURE

may be a chest tube of chest drainage procedure of any type (ie formal tube, pig-tail catheter, etc)

chest drainage

close clinical observation OTHER

close clinical observation in an operating room or intensive care unit without active intervention

close observation

Eligibility Criteria

• Age: 18 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• age \>= 18 years old
• small to moderate sized occult pneumothorax identified on chest or abdominal CT scan
• no chest drain in-situ
• no hemothorax which warrants drainage in the judgment of attending clinician
• no respiratory compromise in the judgment of the attending clinician

You may not qualify if:

• not expected to survive
• large occult pneumothorax
• pneumothorax obvious on plain CXR (not occult)
• respiratory distress in the judgment of the attending clinician
• pre-existing chest drain in-situ

Sponsors & Collaborators

• University of Calgary: lead
• CHU de Quebec-Universite Laval: collaborator
• Sunnybrook Health Sciences Centre: collaborator
• Canadian Intensive Care Foundation: collaborator
• London Health Sciences Centre: collaborator
• Université de Sherbrooke: collaborator

Study Sites (4)

Foothills Medical Centre

Calgary, Alberta, T2N 2T9, Canada

Location

Sunnybrook Health Sciences Centre

Toronto, Ontario, M4N 3M5, Canada

Location

Centre Hospitalier Affilie Universitaire de Quebec

Québec, Quebec, G1J 1Z4, Canada

Location

University of Sherbrooke

Sherbrooke, Canada

Location

Related Publications (33)

• Ball CG, Hameed SM, Evans D, Kortbeek JB, Kirkpatrick AW; Canadian Trauma Trials Collaborative. Occult pneumothorax in the mechanically ventilated trauma patient. Can J Surg. 2003 Oct;46(5):373-9.

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• Ball CG, Kirkpatrick AW, Laupland KB, Fox DL, Litvinchuk S, Dyer DM, Anderson IB, Hameed SM, Kortbeek JB, Mulloy R. Factors related to the failure of radiographic recognition of occult posttraumatic pneumothoraces. Am J Surg. 2005 May;189(5):541-6; discussion 546. doi: 10.1016/j.amjsurg.2005.01.018.

  PMID: 15862493 BACKGROUND

• Ball CG, Kirkpatrick AW, Laupland KB, Fox DI, Nicolaou S, Anderson IB, Hameed SM, Kortbeek JB, Mulloy RR, Litvinchuk S, Boulanger BR. Incidence, risk factors, and outcomes for occult pneumothoraces in victims of major trauma. J Trauma. 2005 Oct;59(4):917-24; discussion 924-5. doi: 10.1097/01.ta.0000174663.46453.86.

  PMID: 16374282 BACKGROUND

• Wall SD, Federle MP, Jeffrey RB, Brett CM. CT diagnosis of unsuspected pneumothorax after blunt abdominal trauma. AJR Am J Roentgenol. 1983 Nov;141(5):919-21. doi: 10.2214/ajr.141.5.919.

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  PMID: 2709459 BACKGROUND

• Hill SL, Edmisten T, Holtzman G, Wright A. The occult pneumothorax: an increasing diagnostic entity in trauma. Am Surg. 1999 Mar;65(3):254-8.

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• Garramone RR Jr, Jacobs LM, Sahdev P. An objective method to measure and manage occult pneumothorax. Surg Gynecol Obstet. 1991 Oct;173(4):257-61.

  PMID: 1925893 BACKGROUND

• Wolfman NT, Myers WS, Glauser SJ, Meredith JW, Chen MY. Validity of CT classification on management of occult pneumothorax: a prospective study. AJR Am J Roentgenol. 1998 Nov;171(5):1317-20. doi: 10.2214/ajr.171.5.9798871.

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• Brasel KJ, Stafford RE, Weigelt JA, Tenquist JE, Borgstrom DC. Treatment of occult pneumothoraces from blunt trauma. J Trauma. 1999 Jun;46(6):987-90; discussion 990-1. doi: 10.1097/00005373-199906000-00001.

  PMID: 10372613 BACKGROUND

• Neff MA, Monk JS Jr, Peters K, Nikhilesh A. Detection of occult pneumothoraces on abdominal computed tomographic scans in trauma patients. J Trauma. 2000 Aug;49(2):281-5. doi: 10.1097/00005373-200008000-00015.

  PMID: 10963540 BACKGROUND

• Tocino IM, Miller MH, Frederick PR, Bahr AL, Thomas F. CT detection of occult pneumothorax in head trauma. AJR Am J Roentgenol. 1984 Nov;143(5):987-90. doi: 10.2214/ajr.143.5.987.

  PMID: 6333171 BACKGROUND

• Trupka A, Waydhas C, Hallfeldt KK, Nast-Kolb D, Pfeifer KJ, Schweiberer L. Value of thoracic computed tomography in the first assessment of severely injured patients with blunt chest trauma: results of a prospective study. J Trauma. 1997 Sep;43(3):405-11; discussion 411-2. doi: 10.1097/00005373-199709000-00003.

  PMID: 9314300 BACKGROUND

• Voggenreiter G, Aufmkolk M, Majetschak M, Assenmacher S, Waydhas C, Obertacke U, Nast-Kolb D. Efficiency of chest computed tomography in critically ill patients with multiple traumas. Crit Care Med. 2000 Apr;28(4):1033-9. doi: 10.1097/00003246-200004000-00020.

  PMID: 10809278 BACKGROUND

• Guerrero-Lopez F, Vazquez-Mata G, Alcazar-Romero PP, Fernandez-Mondejar E, Aguayo-Hoyos E, Linde-Valverde CM. Evaluation of the utility of computed tomography in the initial assessment of the critical care patient with chest trauma. Crit Care Med. 2000 May;28(5):1370-5. doi: 10.1097/00003246-200005000-00018.

  PMID: 10834680 BACKGROUND

• Holmes JF, Brant WE, Bogren HG, London KL, Kuppermann N. Prevalence and importance of pneumothoraces visualized on abdominal computed tomographic scan in children with blunt trauma. J Trauma. 2001 Mar;50(3):516-20. doi: 10.1097/00005373-200103000-00017.

  PMID: 11265032 BACKGROUND

• Rowan KR, Kirkpatrick AW, Liu D, Forkheim KE, Mayo JR, Nicolaou S. Traumatic pneumothorax detection with thoracic US: correlation with chest radiography and CT--initial experience. Radiology. 2002 Oct;225(1):210-4. doi: 10.1148/radiol.2251011102.

  PMID: 12355007 BACKGROUND

• Collins JC, Levine G, Waxman K. Occult traumatic pneumothorax: immediate tube thoracostomy versus expectant management. Am Surg. 1992 Dec;58(12):743-6.

  PMID: 1456598 BACKGROUND

• American College of Surgeons. Advanced trauma life support course for doctors. Committee on Trauma: Instructors' Course Manual. Chicago, 1997.

  BACKGROUND

• Etoch SW, Bar-Natan MF, Miller FB, Richardson JD. Tube thoracostomy. Factors related to complications. Arch Surg. 1995 May;130(5):521-5; discussion 525-6. doi: 10.1001/archsurg.1995.01430050071012.

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• Enderson BL, Abdalla R, Frame SB, Casey MT, Gould H, Maull KI. Tube thoracostomy for occult pneumothorax: a prospective randomized study of its use. J Trauma. 1993 Nov;35(5):726-9; discussion 729-30.

  PMID: 8230337 BACKGROUND

• Wilson H, Ellsmere J, Talon J, Kirkpatrick A. Natural history of the occult pneumothorax in the blunt trauma patient. Journal of Trauma 59(2): 541, 2005.

  BACKGROUND

• Wilson H, Ellsmere J, Tallon J, Kirkpatrick A. Occult pneumothorax in the blunt trauma patient requiring surgery: a qualitative review. Journal of Trauma 59(2): 545, 2005

  BACKGROUND

• Ball CG, Kirkpatrick AW, Fox DL, Laupland KB, Louis LJ, Andrews GD, Dunlop MP, Kortbeek JB, Nicolaou S. Are occult pneumothoraces truly occult or simply missed? J Trauma. 2006 Feb;60(2):294-8 discussion 298-9. doi: 10.1097/01.ta.0000202462.96207.18.

  PMID: 16508485 BACKGROUND

• Sargsyan AE, Hamilton DR, Nicolaou S, Kirkpatrick AW, Campbell MR, Billica RD, Dawson D, Williams DR, Melton SL, Beck G, Forkheim K, Dulchavsky SA. Ultrasound evaluation of the magnitude of pneumothorax: a new concept. Am Surg. 2001 Mar;67(3):232-5; discussion 235-6.

  PMID: 11270880 BACKGROUND

• Kirkpatrick AW, Simons RK, Brown DR, Ng AK, Nicolaou S. Digital hand-held sonography utilised for the focused assessment with sonography for trauma: a pilot study. Ann Acad Med Singap. 2001 Nov;30(6):577-81.

  PMID: 11817283 BACKGROUND

• Kirkpatrick AW, Ng AK, Dulchavsky SA, Lyburn I, Harris A, Torregianni W, Simons RK, Nicolaou S. Sonographic diagnosis of a pneumothorax inapparent on plain radiography: confirmation by computed tomography. J Trauma. 2001 Apr;50(4):750-2. doi: 10.1097/00005373-200104000-00029. No abstract available.

  PMID: 11303179 BACKGROUND

• Cunningham J, Kirkpatrick AW, Nicolaou S, Liu D, Hamilton DR, Lawless B, Lee M, Brown DR, Simons RK. Enhanced recognition of "lung sliding" with power color Doppler imaging in the diagnosis of pneumothorax. J Trauma. 2002 Apr;52(4):769-71. doi: 10.1097/00005373-200204000-00029. No abstract available.

  PMID: 11956400 BACKGROUND

• Dulchavsky SA, Schwarz KL, Kirkpatrick AW, Billica RD, Williams DR, Diebel LN, Campbell MR, Sargysan AE, Hamilton DR. Prospective evaluation of thoracic ultrasound in the detection of pneumothorax. J Trauma. 2001 Feb;50(2):201-5. doi: 10.1097/00005373-200102000-00003.

  PMID: 11242282 BACKGROUND

• Kirkpatrick A, Nicolaou S. The sonographic detection of pneumothoraces (pages 227-234). In: Kharmy-Jones R, Nathens A, Stern E (editors). Thoracic Trauma and Critical Care. Boston: Kleuwer Academic Publishers. 2002.

  BACKGROUND

• Hamilton DR, Sargsyan AE, Kirkpatrick AW, Nicolaou S, Campbell M, Dawson DL, Melton SL, Beck G, Guess T, Rasbury J, Dulchavsky SA. Sonographic detection of pneumothorax and hemothorax in microgravity. Aviat Space Environ Med. 2004 Mar;75(3):272-7.

  PMID: 15018297 BACKGROUND

• Kirkpatrick AW, Sirois M, Laupland KB, Liu D, Rowan K, Ball CG, Hameed SM, Brown R, Simons R, Dulchavsky SA, Hamiilton DR, Nicolaou S. Hand-held thoracic sonography for detecting post-traumatic pneumothoraces: the Extended Focused Assessment with Sonography for Trauma (EFAST). J Trauma. 2004 Aug;57(2):288-95. doi: 10.1097/01.ta.0000133565.88871.e4.

  PMID: 15345974 BACKGROUND

• Kirkpatrick AW, Nicolaou S, Rowan K, Liu D, Cunningham J, Sargsyan AE, Hamilton D, Dulchavsky SA. Thoracic sonography for pneumothorax: the clinical evaluation of an operational space medicine spin-off. Acta Astronaut. 2005 May-Jun;56(9-12):831-8. doi: 10.1016/j.actaastro.2005.01.008.

  PMID: 15835018 BACKGROUND

• Ball CG, Lord J, Laupland KB, Gmora S, Mulloy RH, Ng AK, Schieman C, Kirkpatrick AW. Chest tube complications: how well are we training our residents? Can J Surg. 2007 Dec;50(6):450-8.

  PMID: 18053373 BACKGROUND

MeSH Terms

Conditions

Pneumothorax

Condition Hierarchy (Ancestors)

Pleural Diseases; Respiratory Tract Diseases

Study Officials

• Andrew W Kirkpatrick, MD

  Canadian Trauma Trials Collaborative

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: NONE
• Purpose: TREATMENT
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: Professor

Study Record Dates

• First Submitted: September 13, 2007
• First Posted: September 17, 2007
• Study Start: August 1, 2006
• Primary Completion: January 30, 2021
• Study Completion: January 30, 2021
• Last Updated: April 27, 2021

Record last verified: 2021-04

Data Sharing

• IPD Sharing: Will not share

Locations

CA (4)