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Pneumothorax in the Emergency Department – Part 2

There are multiple controversies in the subject of pneumothorax management, largely driven by the paucity of high-quality evidence in the area. Problems begin with the lack of international consensus on what constitutes a large pneumothorax, which contributes to substantial geographical variation in practice. One thing both the ACCP and BTS can agree on is that small pneumothoraces can be managed conservatively, however they differ in their approach to large pneumothoraces.

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  Pneumothorax Part II: Management In The ED

While spontaneous pneumothorax is a common problem encountered by emergency physicians, there remains regular controversy regarding its appropriate management. The first decision point when evaluating a patient with a spontaneous, non-traumatic pneumothorax is to determine clinical stability. Roberts and Hedges defines a clinically stable patient as having ALL of the following: RR < 24, HR <120, normotensive, O2 sat >90% on RA, and ability to speak in whole sentences between breaths. If the patient is unstable and tension physiology is suspected, urgent decompression is warranted (even in the absence of a confirmatory CXR because tension pneumothorax is a clinical diagnosis). Proceed with needle decompression in the 2nd intercostal space along the mid clavicular line, with a 14g angiocath, or if that fails, emergent pleural decompression using a 10 blade skin incision and blunt dissection with Kelly clamp to enter the pleural space (essentially the beginning steps to placing a surgical chest tube but performed in an emergency even if the kit is not readily available). Definitive treatment is placement of a surgical chest tube.

 Pneumothorax in the Emergency Department – Part 1

Pneumothorax is a relatively rare emergency department presentation with a number of controversies existing regarding its management. Over the last decade, the standard of care has shifted from invasive strategies to more conservation management approaches.

 The Lung is Up Where it Belongs - With or Without a Chest Tube

New research shows more than 90% of patients will be fine without a tube in their chest. If the repeat CXR in about four hours is ok, we will send you home with follow-up with your friendly Thoracik surgeon. You can come back to the emergency department at any time if you are feeling worse or are concerned.

 Ultrasound for Detection of Pneumothorax

The presence of lung sliding in both blunt trauma and critically ill ICU patients can rule out the presence of a pneumothorax

Articles of Interest

EM@3AM: Pneumothorax

FAST is negative, but no lung sliding is seen with ultrasound examination of the right thorax. His trachea is deviated left, and increased JVD is noted.

Episode 36 – Pneumothorax

The 2ICS MCL is Difficult to Find– one study of emergency physicians found that providers could find the 2ICS MCL 60% of the time. Similarly, a blinded cadaveric study in which naval corpsmen who had just had a refresher course in needle decompress were asked to needle decompress cadavers at the 2ICS MCL and 5ICS AAL. They found 80% correct placement in the 5ICS AAL group compared with a mere 30% in the 2ICS MCL group.

Intern Ultrasound of the Month: Pneumothorax

POCUS findings: When the linear probe was placed over the right third and fourth ribs (with the probe indicator pointing cephalad), there was a lack of lung sliding. As the probe was moved slightly laterally and more caudally, a lung point was seen. Not shown here but lung sliding was observed in the basilar segments of the right lung and throughout the left lung. The remainder of the eFAST views revealed no evidence of hemothorax, hemoperitoneum, or hemopericardium.

M-Mode for Pneumothorax

M-mode of the normal lung has been described as having a “Sand on the Beach” appearance. Motion within the lung changes the lung artifacts that return to the machine, creating a speckled appearance like grains of sand beneath the bright pleural line.

Own the Chest Tube!

This time round, we’re going to ‘own the chest tube!’ — as well as the chest drain and a few other things along the way…

Pigtail Catheter Placement

Pigtail catheter placement for traumatic pneumothorax.

Pneumothorax in the ICU

Standard practice is to place a chest tube for any pneumothorax occurring during mechanical ventilation, due to the risk of positive pressure expanding the pneumothorax into a tension pneumothorax.

Pneumothorax: The “PT” Abbreviation

Pneumothoraces can be categorized into spontaneous and traumatic forms.

Tension Pneumothorax

Tension Pneumothorax – time for a re-think?

Tension Pneumothorax- Needle Decompression

Here’s a quick, 3 ½ minute video for physicians and paramedics on how to decompress the chest when you suspect a tension pneumothorax. The ATLS course now adds a consideration to use an alternative site. That location is the 5th intercostal space around the mid-axillary line. This has come about because shorter needles may not reach the pleural space when inserted under the clavicle in larger patients. The new spot is the typical location for placement of the inevitable chest tube that has to be inserted after needle decompression.

Three-step management of pneumothorax: time for a re-think on initial management

Pneumothorax is a common disease worldwide, but surprisingly, its initial management remains controversial.

Resources

SAEM

Spontaneous pneumothorax should be considered in non-trauma patients who complain of dyspnea and/or chest pain. Symptom onset is usually sudden. Other diagnoses that may present similarly to a spontaneous pneumothorax include acute coronary syndrome, thoracic aortic dissection, and pulmonary embolism, as well as pneumonia, pleurisy, and pericarditis.