Traumatic Pneumothorax Data Takes Flight

Conventional medical wisdom has held tightly to Boyle’s law when transporting patients with a traumatic pneumothorax at altitude. A traumatic pneumothorax occurs when air accumulates between the chest wall and injured lung, resulting in partial or complete lung collapse. Based on Boyle’s law, which describes the effect altitude has on gases in closed spaces, as altitude increases, ambient pressure should decrease, causing a pneumothorax to get bigger and further compress the lung. As a result of this principle, doctors often place a chest tube to decompress a pneumothorax before flight — a painful procedure that can delay time to definitive care and cause unnecessary trauma to a child’s body.

Challenging Boyle’s law with data

Through a retrospective study (1) of more than 400 pediatric patients, Children’s Hospital Colorado researchers, led by pediatric surgery research fellow Nicole Becher, MD, and Associate Trauma Medical Director Steven Moulton, MD, aimed to challenge this notion.

“Dogmatic practice has been to place a chest tube before they’re transported, because people are afraid that the pneumothorax is going to expand and hurt the child. And the child’s going to be in a helicopter, where you can’t easily put in a chest tube,” Dr. Becher says. “But that wasn’t based on any data. And so, we said, OK, let’s study it.”

Flying with traumatic pneumothorax at altitude

The team’s data set included 12 years of information on every child that was transported to Children’s Colorado with a known pneumothorax and without a chest tube. The research showed that elevation gain during flight and during ground transport over the Rocky Mountains did not cause complications from pneumothorax expansion in any patients. In fact, just five patients experienced expansion, and none became symptomatic or went into respiratory distress. 

Additionally, the team found that most kids never even needed a chest tube to recover, because most had small pneumothoraxes that resolved on their own. Only 19 patients required a chest tube after arriving at Children’s Colorado, and in those cases, the children had a medium or large pneumothorax prior to leaving their original location.  

“The biggest conclusion we can draw from this is if the patient were staying at your institution and you wouldn’t place a chest tube, don’t place the chest tube prophylactically,” Dr. Becher explains. “There’s no need to place a chest tube just because a child is being transported.”  

“In fact,” she adds, “please don’t.”

Citations

1. Becher, Nicole Alexis et al. “Interfacility Transport of Children with Traumatic Pneumothorax: Does Elevation Make a Difference?.” Journal of pediatric surgery vol. 59,2 (2024): 316-319. doi:10.1016/j.jpedsurg.2023.10.022