Recurrent pneumothoraces in ventilated patients despite ipsilateral chest tubes.

The incidence of recurrent pneumothoraces was analyzed in mechanically ventilated patients with the adult respiratory distress syndrome (ARDS) or non-ARDS causes of respiratory failure who had ipsilateral chest tubes in place. The radiographs of 39 consecutive patients with 47 initial pneumothoraces were evaluated for pneumothorax recurrence and chest tube positioning, which was prospectively defined as having a "vertical" or "horizontal" orientation. "Horizontal" positioning indicated that the chest tube may have been placed into a major fissure or the posterior hemithorax. Sixteen of the 47 pneumothoraces in all study patients, 14 of the 21 pneumothoraces in patients with ARDS, and 2 of the 26 pneumothoraces in patients without ARDS recurred (p < 0.0001) despite an ipsilateral chest tube; 9 of the 14 ARDS pneumothorax recurrences were tension types. "Horizontal" chest tube positioning in patients with ARDS had a positive predictive value of 86% and 64% for recurrences of pneumothoraces and tension pneumothoraces, respectively. Recurrent pneumothoraces occur commonly in mechanically ventilated patients with ARDS despite ipsilateral chest tubes. Because pneumothorax recurrences appear to be related to horizontal chest tube placement, imaging studies should verify that chest tubes are placed in optimally in the anterior hemithorax away from interlobar fissures in this patient population.