Journal Club - Recent Additions

January - 2012


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Diagnosis of Pneumothorax by Radiography and Ultrasonography:

Wu Ding, MM, Yuehong Shen, MM, Jianxin Yang, MM, Xiaojun He, MM and Mao Zhang, MD Chest, 2012, 140:4 859-866


Ultrasound is playing an increasing role in critical care.  This paper describes its use in detection of pneumothorax in the emergency population.  While promising, it requires validation in the ICU environment.


Previous Comments

Liechtenstein's work in the 1990's describing diagnosis of pneumothorax by ultrasound was actually done in the ICU environment, and there have been a lot of studies validating its use. (see this recent review for comprehensive list of references: Basic principles and current applications of lung ultrasonography in the intensive care unit. Stefanidis et al. Respirology. 2011). The main drawbacks appear to be 1) the lack of lung sliding in some patients without pneumothorax such as bullous emphysema or prior pleurodesis yielding false positives, and 2)the practical difficulties of scanning ICU patients who are covered in dressings and equipment and are hard to position adequately. Nevertheless, if you do a 30sec ultrasound pre central line and see lung sliding, aspirate air during the procedure, and then see that's the lung's no longer sliding after the procedure you can get your chest drain in before bothering the radiographers!! Given the difficulties in getting and interpreting radiological investigations in ICU patients, it would seem crazy not embrace quick, point of care ultrasonagraphy performed by the person who actually is the one caring for the patient.
Ed Fysh-01 Feb, 2012 06:41:22 PM

Great points Ed. I think the issue of diseased lung, or more importantly, pleura, is very important. In ED, most significant pneumothoraces will work their way to the top, and scanning will pick them up. In a complicated ICU patient, this might not be the case and it can still be significant, particularly in someone with poorly compliant lungs where a small PTx may still develop considerable pressure.
Todd Fraser-02 Feb, 2012 02:43:39 PM