Spontaneous pneumothorax: use of aspiration and outcomes of management by respiratory and general physicians

Management of Pneumothorax

Pneumothorax is a common medical condition encountered in a wide variety of clinical presentations, ranging from asymptomatic to life threatening. When symptomatic, it is important to remove air from the pleural space and provide re-expansion of the lung. Additionally, patients who experience a spontaneous pneumothorax are at high risk for recurrence, so treatment goals also include recurrence prevention. Several recent studies have evaluated less invasive management strategies for pneumothorax, including conservative or outpatient management. Future studies may help to identify who is greatest at risk for recurrence and direct earlier definitive management strategies, including thoracoscopic surgery, to those patients.

How should complete lung collapse secondary to primary spontaneous pneumothorax be managed?

Management of primary spontaneous pneumothorax (PSP) depends on the symptoms and size of lung collapse. The British Thoracic Society recommends needle aspiration (NA) for all PSP requiring intervention, followed by intercostal drain (ICD) if NA fails. We compared the role of NA versus ICD as the first step in PSP with 'complete lung collapse'.This was a retrospective observational study of 877 consecutive pneumothorax episodes at University Hospitals of North Midlands, Stoke on Trent, UK. Chest X-ray (CXR) at presentation was reviewed to identify PSP with complete lung collapse. The primary outcome measure was successful lung re-inflation after initial intervention.Two-hundred and sixty-six PSP patients were identified; 69 had complete lung collapse on CXR of which 35 had NA and 34 had ICD. The ICD group had a significantly better immediate success compared with the NA group (62% versus 11%, odds ratio (OR) = 12.5, p<0.0001; after adjustment for potential confounders, OR increased to 26.4, p=0.0001) although long-term outcomes were comparable.There should be clear consensus on definition and management of complete lung collapse. PSP with complete lung collapse could be managed as a separate subgroup where ICD placement is considered to be the first intervention.

Shorter Symptoms Onset to Emergency Department Presentation Time Predicts Failure of Needle Aspiration in Primary Spontaneous Pneumothorax

Objective

To evaluate factors in predicting the failure of needle aspiration in primary spontaneous pneumothorax, in particular the interval between symptom onset and emergency department presentation.

Methods

This is a retrospective cohort study carried out from January 2010 to October 2012 in two public hospitals in Hong Kong. All consecutive adult patients aged 18 or more who attended the emergency departments in the study period with the diagnosis of primary spontaneous pneumothorax, where needle aspiration was performed as the primary treatment were recruited. Age, smoking status, previous pneumothorax, symptom interval, size of pneumothorax and aspirated gas volume were included in the analysis. The outcome was successful or failed needle aspiration. Logistic regression was used to identify independent predictors of failed needle aspiration.

Results

A total of 196 patients were included. Overall, 105 patients (53.6%) were treated successfully with no recurrence upon discharge. Among those failure patient, 30 patients (15.3%) failed as evidence by the chest X-ray taken immediately after the procedure while 61 patients (31.1%) failed upon subsequent chest X-ray. Multivariate logistic regression showed factors independently associated with failure of needle aspiration included size of pneumothorax (apex to cupola distance) (odds ratio [OR]=1.022, 95% confidence interval [CI]=1.009-1.039, p=0.001) and symptoms onset to emergency department presentation time (OR=0.987, 95% CI=0.976-0.999, p=0.028).

Conclusions

Large pneumothorax and shorter symptoms onset to emergency department presentation time were associated with higher failure rate of needle aspiration for primary spontaneous pneumothorax. (Hong Kong j.emerg. med. 2014;21:16-22)

The Size of Spontaneous Pneumothorax is a Predictor of Unsuccessful Catheter Drainage

Small-bore thoracic catheter drainage is recommended for a first large or symptomatic episode of primary spontaneous pneumothorax (PSP). However, one-third of these patients require a second procedure because of treatment failure. We investigated the factors associated with unsuccessful pigtail catheter drainage in the management of PSP. In this retrospective study, using a prospectively collected database, we enrolled 253 consecutive patients with PSP who underwent pigtail catheter drainage as initial treatment, from December 2006 to June 2011. The chest radiograph was reviewed in each case and pneumothorax size was estimated according to Light’s index. Other demographic factors and laboratory data were collected via chart review. Pigtail catheter drainage was successful in 71.9% (182/253) of cases. Treatment failure rates were 42.9%, 25.9%, and 15.5% in patients with pneumothorax sizes of >62.6%, 38–62.6%, and <38%, respectively (tertiles). An alternative cut-off point of 92.5% lung collapse was defined using a classification and regression tree method. According to the multivariate analysis, a large-size pneumothorax (p = 0.009) was the only significant predictor of initial pigtail catheter drainage treatment failure in patients with PSP. Early surgical treatment could be considered for those patients with a large-sized pneumothorax.

Simple aspiration and drainage and intrapleural minocycline pleurodesis versus simple aspiration and drainage for the initial treatment of primary spontaneous pneumothorax: an open-label, parallel-group, prospective, randomised, controlled trial

BACKGROUND

Simple aspiration and drainage is a standard initial treatment for primary spontaneous pneumothorax, but the rate of pneumothorax recurrence is substantial. We investigated whether additional minocycline pleurodesis after simple aspiration and drainage reduces the rate of recurrence.

METHODS

In our open-label, parallel-group, prospective, randomised, controlled trial at two hospitals in Taiwan, patients were aged 15-40 years and had a first episode of primary spontaneous pneumothorax with a rim of air greater than 2 cm on chest radiographs, complete lung expansion without air leakage after pigtail catheter drainage, adequate haematological function, and normal renal and hepatic function. After simple aspiration and drainage via a pigtail catheter, patients were randomly assigned (1:1) to receive 300 mg of minocycline pleurodesis or no further treatment (control group). Randomisation was by computer-generated random numbers in sealed envelopes. Our primary endpoint was rate of pneumothorax recurrence at 1 year. This trial is registered with ClinicalTrials.gov (NCT00418392).

FINDINGS

Between Dec 31, 2006, and June 30, 2012, 214 patients were randomly assigned-106 to the minocycline group and 108 to the control group (intention-to-treat population). Treatment was unsuccessful within 7 days of randomisation in 14 patients in the minocycline group and 20 patients in the control group. At 1 year, pneumothoraces had recurred in 31 of 106 (29·2%) patients in the minocycline group compared with 53 of 108 (49·1%) in the control group (p=0·003). We noted no procedure-related complications in either group.

INTERPRETATION

Simple aspiration and drainage followed by minocycline pleurodesis is a safe and more effective treatment for primary spontaneous pneumothorax than is simple aspiration and drainage only. Minocycline pleurodesis should be an adjunct to standard treatment for primary spontaneous pneumothorax.

FUNDING

Department of Health and National Science Council, Taiwan.

Ambulatory treatment in the management of pneumothorax: a systematic review of the literature

INTRODUCTION

Spontaneous pneumothorax (SP) is broken down into primary (PSP: no known underlying lung disease), secondary (SSP: known lung disease) and from trauma or iatrogenic pneumothorax (IP). Current treatments include a conservative approach, needle aspiration, chest drain, suction and surgery. A Heimlich valve (HV) is a lightweight one-way valve designed for the ambulatory treatment of pneumothorax (with an intercostal catheter).

METHODS

We performed a systematic review across nine electronic databases for studies reporting the use of HV for adults with pneumothorax. Randomised controlled trials (RCT), case control studies and case series were included, unrestricted by year of publication. Measures of interest included the use only of a HV to manage SP or IP, (ie, avoidance of further procedures), successful treatment as outpatient (OP) and complications.

RESULTS

Eighteen studies were included reporting on the use of HV in 1235 patients, 992 cases of SP (of which 413 were reported as PSP) and 243 IP. The overall quality of the reports was moderate to poor with high risk of bias. Success with HV alone was 1060/1235 (85.8%) and treatment as OP successful in 761/977 (77.9%). Serious complications are rare. Long-term outcomes are comparable with current treatments.

CONCLUSIONS

High-quality data to support the use of HV for ambulatory treatment of pneumothorax is sparse. The use of HV in such circumstances may have benefits for patient comfort, mobility and avoidance of hospital admission, with comparable outcomes to current practice. There is urgent need for a carefully designed RCT to answer his question.

Evidence-based management of paediatric primary spontaneous pneumothorax

The exact incidence of paediatric primary spontaneous pneumothorax (PSP) is unclear, although PSP incidence in the general population is between 6 and 18 per 100,000. PSP has been reported throughout the paediatric age range. A potential genetic predisposition for familial cases has been recently identified. Whilst there is universal consensus on the management of tension pneumothorax, lack of agreement and consistency exists across a wide range of management issues for other aspects of PSP management. Paediatric PSP may have a higher recurrence rate than adult PSP, and the presence of apical lung cysts or bullae is not predictive of recurrence. The decision for surgical intervention should be based on documented recurrence. There is a lack of paediatric evidence to guide management decisions, and extrapolation of predominantly adult data to younger age groups should not be encouraged. Given the relatively low apparent incidence, a multicentre approach to future research is required in order to generate the evidence required for informed management of PSP in children.

Salvage for unsuccessful aspiration of primary pneumothorax: thoracoscopic surgery or chest tube drainage?

BACKGROUND

Simple aspiration is recommended as first-line treatment for all primary spontaneous pneumothoraces requiring intervention. However, the optimal salvage treatment remains unclear when simple aspiration is unsuccessful for controlling symptoms. In this study, the safety, efficacy, and estimated costs of video-assisted thoracoscopic surgery (VATS) and chest tube drainage (CTD) were compared.

METHODS

Between 2002 and 2007, 164 patients with a first episode of spontaneous pneumothorax were managed by simple aspiration. Among them, 52 patients underwent subsequent VATS (30 patients) or CTD (22 patients) due to unsuccessful aspiration. The demographic data and treatment outcomes of the two groups were collected through retrospective chart review.

RESULTS

Postoperative analgesics use did not differ between groups. Complications developed in 2 of the VATS group (6.7%) and 6 of the CTD group (27.3%), with mean hospital stays of 4.8 and 6.1 days, respectively (p = 0.034). Patients in the VATS group had lower rates of overall failure, although the rates of immediate failure were not significantly different. After a mean follow-up of 16 months, recurrent ipsilateral pneumothorax was noted in 1 VATS patient and 5 CTD individuals (p = 0.038). The estimated total costs per patient were $1,273 in the VATS group and $865 in the CTD group.

CONCLUSIONS

Although associated with higher costs, VATS rather than CTD is the preferred salvage treatment for unsuccessful aspiration of the first episode of primary spontaneous pneumothorax, because of shorter hospital stay and lower rates of overall failure and recurrence.

Review of management of primary spontaneous pneumothorax: is the best evidence clearer 15 years on?

In 1993 Emergency Medicine Australasia (then Emergency Medicine [Fremantle]) published a therapeutic review on the management of spontaneous pneumothorax. That review found a lack of high-quality evidence on which to base management decisions and a variety of therapeutic options without clear superiority one over another. Now, almost 15 years later, the present paper aims to revisit the evidence base to see if management choices are clearer.

Simple aspiration as initial treatment for primary spontaneous pneumothorax: Results of 91 consecutive cases

Varying opinions exist regarding the choice of initial treatment for primary spontaneous pneumothorax (PSP). This study aims to determine the success rate of simple aspiration of PSP, identify factors associated with failure, and identify associated complications. A retrospective analysis was performed on 91 consecutive patients receiving simple aspiration for PSP at the Emergency Department of a university teaching hospital in Hong Kong, China. The overall success rate was 50.5%. Failed cases had significantly larger sizes of pneumothorax, and significantly larger volumes of air aspirated. Pneumothorax size > or =40% was significantly associated with failure. In a multivariate analysis, pneumothorax size > or =40%, compared to size 21-39%, independently predicted failure, with an odds ratio of 8.88 (95% CI, 2.49 to 31.63). Complications were rarely encountered. It is concluded that the success rate may be significantly improved by excluding patients with pneumothorax size 40% or larger from this modality of treatment.

Primary vs delayed surgery for spontaneous pneumothorax in children: which is better?

BACKGROUND

Controversy exists regarding the timing of surgery for spontaneous pneumothorax (SP), which can be performed either after the first development of pneumothorax or after a recurrent spontaneous pneumothorax has occurred. Treatment after recurrence is often adopted because of the purported low recurrence of SP treated nonoperatively and the historical morbidity of open surgery. However, the effectiveness of VATS (to video-assisted bullectomy and pleurodesis) has raised the possibility of performing primary VATS (PV) in all patients. The authors therefore hypothesized that PV is safe and effective for SP and sought to perform a cost-benefit analysis of PV vs secondary VATS (SV).

METHODS

After institutional review board approval, consecutive patients with SP (1991-2003) and no comorbidities were retrospectively divided into PV vs SV. Demographics, recurrent pneumothorax after VATS, length of stay, and costs were compared by Student's t test/chi2. The predicted incremental cost of PV was (cost of PV) - [cost of nonoperative treatment x (1 - recurrence rate)] + cost of SV x recurrence rate. Data are means +/- SEM.

RESULTS

There were 54 spontaneous pneumothoraces in 43 patients (11 bilateral), of whom 3 were excluded because of open thoracotomy. Of 51 pneumothoraces, nonoperative treatment was attempted in 37, of whom 20 recurred and thus required SV. Primary VATS was performed in 14. Both groups had similar age, sex, weight, height, admission heart rate, and room air oxygen saturation. Total treatment length of stay was significantly shorter for PV vs SV (7.1 +/- 0.96 vs 10.5 +/- 1.2, P = .04). However, morbidity from recurrent pneumothorax after VATS occurred more frequently after PV than SV (4/14 vs 0/20 P < .05). Based on the observed recurrence rate of 54%, performing PV on all patients with SP would increase cost by $4010 per patient and require a recurrence rate of 72% or more to financially justify this approach.

CONCLUSIONS

Contrary to the hypothesis, the increased morbidity and cost do not justify a strategy of PV blebectomy/pleurodesis in children with SP. Instead, secondary treatment is recommended.

Pneumothorax

Spontaneous pneumothoraces can occur without obvious underlying lung disease (primary) or in patients with known underlying lung disease (secondary). Management guidelines for spontaneous pneumothorax have been published by major professional organizations, but awareness and application among clinicians seems poor. First episodes of primary spontaneous pneumothorax can be managed with observation if the pneumothorax is small. If the pneumothorax is large or if the patient is symptomatic, manual aspiration via a small catheter or insertion of a small-bore catheter coupled to a Heimlich valve or water-seal device, should be performed. In general, definitive measures to prevent recurrence are recommended after the first recurrence of the pneumothorax, and can be achieved by medical (e.g. talc) or surgical (video-assisted thoracic surgery) pleurodesis. Secondary pneumothoraces should be treated with chest tube drainage followed by pleurodesis after the first episode to minimize any risk of recurrence. Traumatic pneumothoraces may be occult (not seen on an initial CXR) or non-occult. The majority are treated by placement of a chest tube. Selected patients may be treated conservatively, with approximately 10% of these patients eventually requiring chest tube placement. Iatrogenic pneumothoraces have a myriad of causes with transthoracic lung needle biopsy being most common. Transthoracic needle biopsy-related pneumothoraces have CT findings that can predict their occurrence and the need for chest tube placement. Iatrogenic pneumothoraces, regardless of cause, may be managed by observation or small bore chest tube placement, depending upon patient stability and the size of the pneumothorax.

[Pneumothorax]

During traumatic lesions, lung diseases or even spontaneously air can reach the pleural cavity causing a so called pneumothorax. If a valve mechanism develops, the high pressure in the pleural cavity impaires the blood flow to the heart, causing a circulatory insufficiency. This situation can develop very quickly and therefore must be very fast diagnosed and treated because of the life threatening character. Clinical symptoms and findings should be the main stay in the diagnosis. X-ray and CT may provide additional information concerning the cause of the disease. The therapy consists of draining the air by tube suction or by surgical closing of the leak in the pleura. The paper gives some practical information concerning the therapy.