Andy Steval 29/09/2015

Pneumothorax management

• Pathophysiology • Diagnosis• Brief review of management • Discussion of recent literature

Introduction

• https://youtu.be/hjQupYskOZw?t=1678• https://youtu.be/wDHOubwvRdg?t=1733

Anatomy Refresher

Back to the 90’s with Robert Acland

• Air between parietal and visceral pleura

Pathophysiology

Traumatic:

Perforation of parietal or visceral pleura

Spontaneous:

Rupture of sub- pleural bullae.

Primary

Secondary

• PA erect CXR: Sensitivity 83% 1

• CT chest: Much higher• Ultrasound: Sensitivity approaching 100%1

Diagnosis

Spontaneous pneumothorax – Management2

Boring

Spontaneous pneumothorax - Management

Primary < 2 cm and

clinically well

Probable discharge with early follow up

> 2 cm or unwell

Needle/catheter aspiration

Success?

Generally all require admission

<1cm – Oxygen 1-2cm – Needle/catheter aspiration>2cm / unwell – Small bore chest drain

Secondary

• Needle Aspiration:• “Simple aspiration under LA with 14-16 G cannula, until

resistance is felt, patient coughs excessively or over 2.5 litres withdrawn:”3

• Evidence that simple needle aspiration is just as effective as ICC insertion but leads to fewer hospital admissions and less analgesic requirements. 4

• Repeat CXR 6 hours later and discharge if successful

Spontaneous pneumothorax - Management

• Management of Emergency Department Patients With Primary Spontaneous Pneumothorax: Needle Aspiration or Tube Thoracostomy? Shahriar Zehtabchi, MD, , Claritza L. Rios, MD. Annals emergency medicine Volume 51, Issue 1, January 2008, Pages 91–100.e1

• Literature review of three prospective, randomised controlled trails

• All three studies only including patients with primary spontaneous pneumothoracies

• Same failure rates between both procedures at immediate, 1-week and 1 year time periods (Approximately 40%, 10% and 25% respectively)

Needle aspiration or tube thoracostomy?4

• Approximately half the rate of hospital admissions for those receiving needle aspiration

• Higher pain scores reported for those receiving tube thoracostomy

• Also higher complication rates (tube blockage, infection, surgical emphysema)

• No mention of tube thoracostomy size/type used – pigtail catheter or surgical chest drain ?

• Not applicable for those with secondary spontaneous pneumothoracies

Needle aspiration or tube thoracostomy?

• Retrospective study from 2014 looking at outpatient management of both primary and secondary large pneumothoracies with pigtail catheters

• 132 patients in study group

• All discharged 2 hours post observation in ED following placement of pigtail catheter with 1-way valve fitted. No imaging done.

• Followed up by outpatient respiratory team at day 2

• 78% success rate with outpatient management alone

Ambulatory management of large spontaneous pneumothorax with pigtail catheters. Voisin F1, Sohier L2, Rochas Y2, Kerjouan M3, Ricordel C3, Belleguic C3, Desrues B3, Jouneau S4.Ann Emerg Med. 2014 Sep;64(3):222-8. doi: 10.1016/j.annemergmed.2013.12.017. Epub 2014 Jan 15.

Spontaneous pneumothorax - Management

https://www.youtube.com/watch?v=jk19A8v7TtA

Here’s how I insert a pigtail catheter

Spontaneous pneumothorax – Follow up 5

• Patients should be advised to return to hospital if increasing breathlessness develops.

• All patients should be followed up by respiratory physicians until full resolution. (CXR 2-4 weeks post discharge)

• Air travel should be avoided until >1 week after full resolution.

• Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy

1. Tinitinallis’ emergency medicine

2. https://www.brit-thoracic.org.uk/document-library/clinical-information/pleural-disease/pleural-disease-guidelines-2010/pleural-disease-guideline/

3. http://lifeinthefastlane.com/ebm-spontaneous-pneumothorax/

4. Ann Emerg Med. 2008 Jan;51(1):91-100, 100.e1. doi: 10.1016/j.annemergmed.2007.06.009. Epub 2007 Sep 29.Management of emergency department patients with primary spontaneous pneumothorax: needle aspiration or tube thoracostomy? Zehtabchi S1, Rios CL.

5. Ambulatory management of large spontaneous pneumothorax with pigtail catheters. Voisin F1, Sohier L2, Rochas Y2, Kerjouan M3, Ricordel C3, Belleguic C3, Desrues B3, Jouneau S4.Ann Emerg Med. 2014 Sep;64(3):222-8. doi: 10.1016/j.annemergmed.2013.12.017. Epub 2014 Jan 15.

References