Spontaneous pneumothorax: Are we treating the patient or the xray?

SPONTANEOUS PNEUMOTHORAX:

ARE WE TREATING THE CXR OR THE

PATIENT?

January 2015

@kellyam_jec

Permission

This presentation may be used freely for

educational purposes

It is the responsibility of the user to ensure that

the content is up to date and relevant to their

practice environment

Conflicts of interest

None to declare

Objectives

To review current evidence-based

guidelines for management of

spontaneous pneumothorax

To discuss the practical challenges in

managing spontaneous

pneumothorax

Before we start ...

According to recent guidelines, which

of the following should be the main

determinant of ED therapeutic

intervention in primary spontaneous

pneumothorax?

A. Pneumothorax size

B. Presence or absence of significant

breathlessness

C. Previous spontaneous

pneumothorax

D. Occupation

Mike

Aged 19

Onset of pleuritic chest pain yesterday

Mildly SOB on exertion only

Smoker, no other past history

At rest, pulse 60, O2

sat 98% (on room air), other vital signs normal

What would you do?

A. Large bore intercostal catheter

(ICC) and underwater-seal drain

(UWSD)

B. Small bore ICC and Heimlich

valve/ UWSD

C. Aspirate

D. Nothing –conservative

management with outpatient followup

E. Admit to ED observation ward for

oxygen therapy

Would this xray change your

mind?

Same history,

symptoms and

vital signs

Epidemiology

Primary spontaneous pneumothorax

is a disease of the young

Peak incidence late teens/ twenties

Male> Female; about 4:1

Smoking is a major risk factor

Clinical features

Chest pain: 90%

Sharp, dull

Dyspnoea- but can be transient

Presentation delayed > 24 hours in >50% of patients

Signs

Resonant chest

Reduced breath sounds

May be subtle depending on size, chest wall thickness, etc.

Imaging

Chest xray Erect CXR is highly sensitive for clinically

relevant pneumothorax

Expiratory films add little and should be avoided

Supine films are of little use

CT Highly sensitive and can identify other

pathology

Concern that overcalls clinically irrelevant pneumothorax

Ultrasound Used in trauma and increasing accepted in

non-trauma

A question of size?

No international agreement on size

definitions!

Australia and UK

Small: <2 cm rim around lung (measured at

hilum)

US

Small: <3cm inter-pleural distance at apex

US

method

UK and Australian

method

International variation in

guidelines

Guideline Year Definition of

‘large’

pneumothora

x

Management

recommendation for

‘large’ pneumothorax

in stable patient

British Thoracic

Society

2010 >2cm

interpleural

distance at

hilum

Conservative if minimal

symptoms, otherwise

aspiration

American

College of

Chest

Physicians

2001 >3cm apical

interpleural

distance

Pleural catheter insertion

(small bore or ICC) with

UWSD

Belgian Society

for

Pulmonology

2005 Interpleural gap

along entire

length of lateral

chest wall

Aspiration or pleural

catheter insertion with

USWD/valve

Therapeutic

guidelines

(Australia)

2014 >2cm

interpleural

distance at

hilum

Aspiration


opinionsRegion/count

ry

Year

of

repo

rt

Comment

Wales 2000 Small PT not breathless only 50% would

treat conservatively.

Initial treatment of moderate/large: 75%

would aspirate

USA 1997 20% PSP in well young patient:

conservative 52%; aspirate 14%, pleural

catheter 31%

Czechoslovaki

a

2008 First PSP: 69% pleural catheter, 6%

aspiration

Switzerland 2006 Stable first large PSP: High consensus

for insertion pleural catheter; no support

for conservativeWales: Yeoh et al, Post Grad Med J; USA: Baumann et al, Chest;

Czech: Stolz et al, Rozhl Chir; Switz: Kuester et al, Interact

Cardiovas Thorac Surg


practice

Country/

Region

Size Year

of

repor

t

Conservati

ve

Aspiratio

nPleural

catheter

drainage

Hong

Kong

(N=12)

Large 2009 2% 18% 80%

Australia

(N=19)

Large 2008 10% 17% 72%

UK (N=1) Large 2002 0% 75% 25%

Singapore

(N=1,

SGH)

All 2004 35% 18% 47%

HK: Chan et al, HK Med J; Aus: Kelly et al, Int Med J; UK: Mendis et al,

Post Grad Med J; Sing: Ong et al, Eur JEM.

Different perspectives

Multiple speciality groups involved:

Emergency physicians

Respiratory physicians

Thoracic surgeons

General physicians

General surgeons

Evidence of variation in practice and opinion

EP and respiratory physicians are more comfortable with conservative management

General physicians and surgeons favour pleural drainage as initial intervention

What does this tell us?

There is international and inter-disciplinary lack of consensus regarding management strategies

The various national guidelines are not being followed

There is variation in how the available evidence is being interpreted Same evidence, different recommendations

The evidence

Evidence base is NOT strong

Factors to consider:

Type of pneumothorax: primary or secondary

Clinical evidence of respiratory compromise, in particular significant breathlessness

Size: Pneumothoraces resolve at a rate of approximately 1.25 to 2.2% of the volume of hemithorax per day.

Age: Evidence suggests that aspiration is less successful in patients aged over 50.

Availability of followup

Emergent drainage

Who?

Patients with severe respiratory compromise

Patients with shock

How?

14G IV catheter

Small bore catheter (e.g. Cook’s) via Seldinger technique

Definitive treatment required

Problems with IV catheter emergent

drainage

Traditional recommendation has been

14G, 5cm needle in second intercostal

space

Radiological studies:

24-42% of people have chest wall

thickness at 2ICS >5cm.

Chest wall thickness increases steadily

with BMI

Cadaver study:

Average chest wall thickness >4cm

Only 58% of 14G, 5cm needles entered

pleural space

Solutions

Use a longer needle

Go straight for a

Seldinger-type kit

Quick

Has long needle

Connects directly to

drainage so no

secondary procedure

required

Minimal symptoms

Evidence supports conservative treatment irrespective of size on xray

Re-absorb at rate of 1.5-2.3% hemithorax/ day

Can be managed at home!

Follow-up

Weekly is safe (some use 2-4 weekly)

Caveat: for early presenters (<24 hours), may be prudent to check in 4-6 hours and next day

Key questions

What is the risk of progression to tension

pneumothorax?

Negligible –none reported in literature

How long should I keep the patient in ED

or observation ward?

If symptoms >24 hours, no need to observe

If symptoms <24 hours, most would re-xray after

4-6 hours ‘just in case’ – not evidence-based

How do I arrange appropriate follow-up?

Very important, but depends on local factors

Symptomatic

Main indication for intervention is

presence of significant

breathlessness

Options

Aspiration

Catheter drainage

Small bore

Large bore

Pigtail catheters / similar

Aspiration

Usually performed using a small catheter inserted by Seldinger technique

Aim is to convert a large pneumothorax to a small one

Success = rim <2cm and resolution of breathlessness without re-accumulation over 4-6 hours

Success rate 50-80%

Predictors of failure

Much less likely to be successful if

patient aged >50 years

If you have aspirated >3 litres,

success unlikely

Connect to Heimlich valve or UWSD

Key questions

What site should be used?

Second ICS mid-clavicular line or 4 ICS

mid axillary line

How long should I observe the

patient after successful drainage?

4-6 hours is probably enough

Need to check no re-accumulation

Catheter drainage

Small bore catheters (5-16F) are as effective as large catheters Many inserted by Seldinger-type approach

Success rate 65-95%

Suction does not improve outcome and should be avoided

Trocars should not be used

Complication rate of ‘traditional’ open catheter insertion 5-10% (excludes persistent air leak).

Key questions

Where should I insert a pleural

catheter?

If using small catheter, either anterior or

lateral is fine

If using large catheter, lateral side

preferred for aesthetic and comfort

reasons

Are large bore catheters really

‘out’?

Yes!

No evidence of benefit, more

uncomfortable, high complication rate

Surgery

About 10% of patients require surgical intervention

Indications:

persistent air leak after 2-7 days

recurrent pneumothoraces

airline pilots, frequent plane travelers and divers

contralateral or bilateral pneumothoraces and

pregnancy

Ambulatory management

optionsCountry/

region

Year

of

report

Study

design

Findings

Singapore 2011 RCT Aspiration vs mini chest tube. No

difference in outcome; ~50%

discharge from ED

France 1 2014 Case

series

Pigtail catheter + valve. 78%

success rate

France 2 2014 Case

series

Pigtail catheter + valve, 83%

success rate; 60% treated as

outpatients

Canada 2009 Case

series

Small bore catheter + valve; 81%

discharged from ED; 60%

managed totally as outpatients

Japan 2014 Case

series

Small bore catheter + valve; 94%

success rateSingapore: Ho et al, Am J Emerg Med 2011; France 1: Voisin et al, Ann Emerg med 2014;

France 2: Massongo et al, Eur Respir J, 2014; Canada: Hassani et al, Acad Emerg Med 2009;

Japan: Karaskai et al, Thorac Cardiovasc Surg

All

concluded

outpatient

management

was safe.

The bottom line

If asymptomatic/ minimal symptoms, conservative management as outpatient is safe

Aspiration is worth a try in young patients

If a pleural catheter is indicated, a small (or pigtail catheter) is as good as a large catheter

Outpatient management with pigtail catheter and valve is safe in selected patients

Recurrence

Up to 50% after first pneumothorax

Greatest risk in first year

Up to 70% after subsequent

pneumothorax

Revisiting

Which of the following is the main



pneumothorax?


B. Presence or absence of significant

breathlessness


pneumothorax

D. Occupation

Revisiting

Which of the following is the main



pneumothorax?


B. Presence or absence of

breathlessness


pneumothorax

D. Occupation

Did you change your mind?

Aged 19

Onset of pleuritic

chest pain yesterday

Mildly SOB on

exertion

Smoker, no past

history

At rest, pulse 60, O2

sat 98% on room air


Same history,

symptoms and

vital signs


Same history, symptoms

and vital signs

I would treat both of

these conservatively

as outpatients

Question #1

23 year old man

50% pneumothorax with minimal

symptoms

Past history of ipsilateral PSP a year

ago

What is the preferred treatment option?

Question #1

No intervention needed in ED

Refer to thoracic surgery team for

definitive procedure (can be as

outpatient)

Question #1a

Same history

Pneumothorax ~70% and significant

breathlessness

What should be done?

Question #1a

This is an evidence free zone

Definitive procedure recommended as likelihood of further recurrence is very high (>70%)

Options:

Aspirate – if successful, home for semi-elective thoracic surgical procedure

Small bore/pigtail catheter – as outpatient/ inpatient

Primary thoracoscopy without ED intervention

Question #2

Can I send a patient home with a

pigtail (similar) catheter and one

way valve in situ?

Question #3

Is it safe to observe (treat

conservatively) a young patient

with large first PSP who has

minimal symptoms?

Question #3

The evidence says ‘YES’

Require:

Sensible patient

Access to appropriate followup

Means of return to hospital if gets worse

Question #4

What advice should I give about

work, flying and return to sport?

Question #4

Evidence-free zone

Return to work is OK as long as

symptoms are resolved

Air travel should be avoided until full

resolution confirmed by xray

Most airlines have a rule requiring 1 week

after full resolution

Sports are OK

Caveat: reasonable to avoid sports with

extreme exertion or contact until full

resolution

Question #5

Are there trials comparing

aspiration / small bore catheter

management with traditional large

bore pleural catheter management

for clinically significant outcomes?

Question #5

Clinically significant outcomes

Requirement for hospital admission

Requirement for secondary procedure

Requirement for surgery

Recurrence

Question #5

Aspiration vs. chest tube Cochrane review (CD 004479)

No difference in immediate success rate, early failure rate, duration of hospitalisation, one year success rate and number of patients requiring pleurodesis at one year.

Aspiration had lower admission rate

Small vs. Large pleural catheters Several RCT comparing small and large

catheters show similar outcomes (methodological issues)

Large bore catheters inserted by ‘open’ technique may have higher complication rate

Thankyou @kellyam_jec

Research opportunity

Do defined high risk features identify patients

who require definitive surgical intervention for

radial fracture?

Instability markers: age >60, intra-articular,

osteoporosis, dorsal angulation >20%, ulna

fracture, dorsal comminution, radial shortening

>3 instability markers, outcome was better with

surgery

What is involved?

Reviewing medical records for demographics,

mechanism of injury and instability markers

Reviewing xrays/ reports for instability markers

Participating in interpretation of data

What is in it for me?

Taste of research

Opportunity to be published

Opportunity to present at local / national

conferences

Spontaneous pneumothorax: Are we treating the patient or the xray?

Health & Medicine

Transcript of Spontaneous pneumothorax: Are we treating the patient or the xray?