Page 46 - JSOM Winter 2022

(68%; 17/25) occurred with 0mL EBL. 24% (6/25) occurred demonstrated no difference in procedural time between the
with 1mL, and 8% (2/25) occurred with >1mL. The majority two techniques. However, the participants in this study were
of RT (72%; 18/25) insertions yielded 0mL EBL. 16% (4/25) surgical residents and were likely more practiced in the open
occurred with 1mL, and 12% (3/25) occurred with >1mL. tube thoracostomy technique than most first responders. Ad-
There was no difference in procedures exceeding EBL >0mL ditionally, this was a controlled environment with the thorax
between OT and RT groups 32% versus 28%; p = .83). exposed and the operating table elevated and does not account
for the challenges of far forward chest tube placement on the
battlefield. Therefore, we suspect that the speed of perfor-
Discussion
mance of traditional tube thoracostomy in this study is not
Simple pneumothorax in trauma has the potential to prog- representative of the actual time required for nonsurgical field
ress to tension pneumothorax with detrimental physiologic personnel to perform the same procedure. In this study, open
derangements. In the civilian setting, observation and clinical tube thoracostomy insertions were completed in less than
judgement can be used rather than decompressive interven- 40 seconds by surgical personnel. In a 2018 study from the
tion. However, the combat environment presents unique chal- University of Maryland School of Medicine, medical students
lenges, including potential for ongoing combat, evacuation and paramedics with no experience with the procedure were
delay, lack of pressurized cabins in air evacuation, and inabil- evaluated for speed of completion of tube thoracostomy. The
14
ity to monitor patients closely during transport (i.e., inaudible average insertion time in this group was 76.9 seconds, with
breath sounds on evacuation helicopter). These factors limit some tube placements requiring up to 106.9 seconds. Compar-
the realistic application of observation for traumatic pneu- atively, the same study recorded an average insertion time of
mothorax, thereby prioritizing effective decompression of the 47.3 seconds with the Reactor device (also with medical stu-
chest and lowering the threshold at which decompression is dents and paramedics without any experience with the device).
considered the appropriate intervention. This creates a need Although the study also fails to replicate the combat or field
for an effective and safe method of managing pneumothorax environment, it is likely a better representation of the relative
in combat environments. While the role of needle decompres- speeds with which each procedure could be completed by non-
sion in management of traumatic pneumothorax in this envi- surgical personnel.
ronment is controversial, evacuation of air in the pleural space
remains a priority. Several devices have been developed for Although this study noted differences between optimal and
11

this, including the Reactor device. suboptimal placement, it should be noted that all chest tubes
placed into the intrapleural space successfully relieved simple
The Reactor has been validated in past models for tension pneumothorax except for one. This is an important consider-
10
pneumothorax. Previous models showed a lack of consistent ation, as even suboptimal placement prevented the potential
therapeutic effect of needle decompression for tension pathol- progression to life-threatening tension pneumothorax. In the
ogy; this effect was improved with the use of the Reactor. pre-hospital setting, the avoidance of life-threatening tension
10
However, not all chest injuries or pneumothoraces present physiology by decompression of the chest supersedes perfect
with tension physiology, and needle decompression is a tem- placement of the tube, particularly in the absence of complica-
porizing maneuver. The benefit of the Reactor technique has tions. This study did not demonstrate a significant difference in
not previously been evaluated in simple pneumothorax or in complications between the two techniques, regardless of place-
comparison to standard open thoracostomy. ment. This is critical; the Reactor is non-inferior compared to
the traditional technique with respect to chest tube placement,
This study demonstrated that the Reactor was noninferior to indicating that follow-up studies may prove beneficial.
open tube thoracostomy, with equal resolution rates. Addi-

tionally, this study demonstrated that the Reactor was associ- Limitations of this study include a limited number of interven-
ated with smaller incisions and equal resolution rate compared tions (n = 50) and limited tissue specimens (n = 5). The num-
to open thoracostomy without adding procedural time. The ber of specimens relative to the number of interventions meant

Reactorcan treat simple pneumothoraces as quickly and effec- that the specimens were used recurrently; natural variability
tively, but with smaller incisions. among thoracic cavities was limited and tissue was damaged
with each insertion. Additionally, this study’s participants were
EBL was not significantly different between the groups, with limited to two surgical residents, further limiting the variabil-
only 32% and 28% of insertions exceeding 1mL EBL in OT ity among insertions. Together, these factors limited measures
and RT groups, respectively (p = .8273). However, incision of significance. The participation of trained surgical personnel,
length between the groups was significantly different, with with an average of 15 prior tube thoracostomies on patients
average length for OT of 3.5 cm versus 2.7 cm for the Re- prior to participation, may limit the application of this data
actor group (p = .0072). Smaller incisions allow less surface to the target group. This protocol did not incorporate condi-
area for wound contamination and may be beneficial in the tions to replicate use of this device in the field by prehospi-
12
long term. Additionally, smaller incision may prevent air leak tal personnel and may not account for additional stressors or
around the tube – especially when placed in a battlefield sce- variability in such applications. The assessor-blinded model of
nario with patient movement and evacuation considerations. 13 this study accounted for biases in assessment of the method of
placement and individual surgeon performance. Additionally,
The major barriers to adoption of traditional thoracostomy the randomized cross-over design of this study addressed the
in prehospital management of pneumothorax is the layered bias of familiarity with either technique, learning curve with
steps of the technique and time consumption. Therefore, a use, and practice. Limitations of the product should also be
key consideration in evaluating the effectiveness of the Reac- mentioned: the device does not allow for “finger sweep” be-
tor compared to open thoracostomy is the speed and relative fore insertion of the tube. The construction of the device is best
ease with which the intervention can be performed. This study suited for one time use in a sterile environment and durability

44 | JSOM Volume 22, Edition 4 / Winter 2022