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The authors intended to systematically review the available Study Selection and Data Collection
evidence in the literature concerning chest seal adherence and Studies were placed in the Rayyan QCRI (https://www.rayyan
the ability to prevent tension pneumothoraces in patients with .ai/) web-based systematic review application. A blinded
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penetrating chest trauma. initial screening was conducted by two investigators (RP, PA)
using titles and abstracts, based on inclusion and exclusion
criteria in Table 2. For example, qualitative case reports of
Research Question
chest seals for penetrating chest trauma and articles in which
The goal was to answer the following questions concerning chest seals were applied for postoperative complications were
chest seals when used to treat an open pneumothorax caused excluded. A third blinded reviewer (MQ) was a tiebreaker on
by penetrating trauma: 1) Which chest seals have superior ad- two articles, and one was excluded for being a qualitative re-
herence to skin as compared to other commercially available view as it was an article discussing chest seal use in austere
chest seals? 2) Which chest seals have a superior ability to pre- environments. A full-text review of the remaining articles by
vent tension pneumothoraces, as compared to other commer- two investigators (RP, MQ) was conducted based on exclusion
cially available chest seals? criteria. One study was excluded for being a qualitative update
to treatment guidelines (Figure 1).
Methods
TABLE 2 Inclusion and Exclusion Criteria
The systematic review was conducted in accordance with the Published or presented in English
PRIMSA 2009 standards systematic review methodology, ex- Manuscript from 1990 to 2020
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cept where noted. A formal protocol was not published prior Inclusion Criteria
to this article. Type of studies • Quantitative experimental design
Type of outcomes • Adherence to skin
Eligibility Criteria • Prevention of a radiographic tension
All English-language, full manuscript, experimental, quanti- pneumothorax
tative studies of humans and animals concerning chest seal • Prevention of physiologic changes
adherence or efficacy written and yet to be published or pub- associated to a tension pneumothorax
lished from 1990 to 2020 were considered for the review. • Reduced mortality
Type of intervention(s) • Adherence - Wet, dry, or soiled skin
or phenomena of • Type of chest seal – Nonocclusive or
To be included in this review, studies had to experimentally interest occlusive
quantify device adherence or effectiveness at preventing ten- • Medical indication – Open
sion pneumothorax-related changes when used to treat pene- pneumothorax, tension pneumothorax,
trating chest trauma in a human or animal model. The ability hemopneumothorax
to remain physically in place can be further expanded into the • Environmental conditions –
Temperature, wound contaminants
device’s ability to adhere to the patient’s skin during initial Type of participants • Animal or human adult subjects
placement, adherence over time, and readherence after tempo- Exclusion Criteria
rary removal for “burping.” A chest seal’s effectiveness at pre-
venting tension pneumothoraces is determined by the device’s • Case studies or articles that are
purely descriptive or do not provide
vent/valve ability and can be monitored via patient hemody- quantitative measurements
namics, intrapleural pressure, radiographs, or survivability • Studies of conditions caused by
after placement over an open pneumothorax. Publications of complications of a medical or surgical
chest seals being used in the treatment of procedural complica- intervention
tions, sequelae of known medical or surgical disease, or those • Studies of conditions caused by
of a descriptive nature were excluded. complications of an existing pathology

Data Sources and Search Strategy The included articles were reviewed, and the data extracted
Three electronic databases MEDLINE, CINAHL and Scopus from each study included primary outcome, participant type,
were searched using the terms ((((((((((((thoracic injuries[MeSH chest seals tested, method of measurement, and published re-
Terms]) OR pneumothorax) OR hemopneumothorax) OR sults. Data collection was performed independently and un-
(chest wound OR chest wounds))) AND (((Tissue Adhe- blinded for each study.
sives[MeSH Terms]) OR (seal OR seals)) OR (dressing OR dress-
ings)))))) AND (“1990/01/01”[PDat]: “2020/08/31”[PDat])))). Assessment of Bias and Synthesis of Results
A three-step search strategy was used in this review. Scoping searches confirmed that nearly all eligible articles
would not be in the form of blinded, randomized controlled
An initial limited search of MEDLINE was followed by analy- trials and would have moderate risk of bias. Additionally, the
sis of the text words contained in the title and abstract, as well heterogeneous nature of the study designs and outcome mea-
as of the index terms used to describe the articles. A second sures would prevent extensive quantitative data synthesis. For
search using all identified keywords and index terms was then these reasons, standardized assessments of evidence quality or
performed across all included databases. The reference lists of risk of bias were not used for the included articles. The articles
applicable reviews and all included articles were also exam- are sorted by whether the primary outcome was to test adher-
ined for further potentially relevant studies. Gray sources such ence and vent/valve function independently of each other, or as
as textbooks, conference proceedings, committee reports, dis- a combined overall outcome. Results are summarized in nar-
sertations, websites, and clinical trial registries were searched rative/tabular forms and the relevant methodological features
using AccessMedicine, Defense Technical Information Center, are highlighted. A weighted scoring system similar to that used
ProQuest, and the open internet. by Montgomery et al., to assess tourniquet performance, was

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