HWN Suggests

Management of Primary Spontaneous Pneumothorax

There is perhaps no single diagnosis where we see such a huge practice variation than in the management of spontaneous pneumothorax. Even the definition of what a large, tube-in-the-chest-worthy pneumothorax is different depending on where you practice. Management options for small and large spontaneous pneumothorax are all over the place – observation alone, pigtail catheter with Heimlich valve, needle aspiration, large-bore chest tube, underwater seal or suction. There are significant complications associated with each of these options...

Defining the size of a pneumothorax guides subsequent management decisions. Unfortunately there is no agreed upon universal definition…

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 Conservative treatment for primary spontaneous pneumothorax

A new paper was published this month that is likely to change the way that a lot of people manage spontaneous pneumothorax (although I don’t think it will significantly change my practice)…

 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.

 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.

 Spontaneous Pneumothorax – Management

Patients who are asymptomatic (no respiratory distress) with pneumothoraces < 3cm from the apex can be managed conservatively with minimum symptomatology. For those with a pneumothorax > 3cm, use a small pigtail or pneumothorax catheter (8-14F) and either manually aspirate the air, attach to Heimlich valve, or attach to wall suction. Patients whose lungs remain expanded after 4-6 hours with a closed valve, may be safely discharged home after removing the tube. Alternatively, they can be discharged home with a closed tube and removed the next day if the lung remains expanded. All patient should receive a follow-up chest x-ray in 24h.

 Spontaneous Pneumothorax: Stand There and Do Nothing?

In a select and carefully identified subset of patients with large primary spontaneous pneumothorax in a clinical setting that can accommodate both observation and potential emergent intervention, a conservative management approach of observation may obviate the need for chest tubes. For many clinicians, this strategy may not be feasible. The authors of this trial have posed a critical question and laid the foundation for a shift in the management of larger primary spontaneous pneumothoraces.

 The RAMPP Trial: Randomised Ambulatory Management of Primary Pneumothorax

The increased risk of serious adverse events and the need for repeated close outpatient follow-up by a clinician trained to manage pneumothoraces and chest drains in the ambulatory cohort seem too much to overcome for most patients and clinicians. However, it may be a viable option for some with careful selection and shared decision-making. Perhaps a better strategy is to apply O2 and repeat CXR in 4 hours before attempting any invasive procedure.

 What’s the Best Intervention for Primary Spontaneous Pneumothorax?

In an otherwise appropriate patient with a stable, non-enlarging pneumothorax, the best intervention may be the lack thereof.

Articles of Interest

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…

Update: Is Needle Aspiration Better Than Chest Tube Placement for the Management of Primary Spontaneous Pneumothorax?

Chest tube placement is successful more often than needle aspiration in the treatment of primary spontaneous pneumothorax, yet is associated with longer hospital length of stay and potentially more adverse events. Therefore, both needle aspiration and chest tube placement are reasonable first-line options, depending on individual patient preferences and circumstances.

First-time Spontaneous Pneumothorax Management with Simple Aspiration

The clinical presentation of pneumothorax is highly variable. Spontaneous pneumothoraces may present with subtle symptoms when a small air leak is present, but can progress to hemodynamic instability in the setting of tension physiology.

How spontaneous pneumothorax is managed in emergency departments: a French multicentre descriptive study

Management of spontaneous pneumothorax (SP) is still subject to debate. Although encouraging results of recent studies about outpatient management with chest drains fitted with a one-way valve, no data exist concerning application of this strategy in real life conditions.

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.

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. Traumatic pneumothoraces (including iatrogenic) will also present with chest pain and dyspnea, but in temporal proximity to a traumatic event or invasive procedure.

Thoracic Vent

UreSil is a leading global provider of innovative devices for the specialized field of interventional radiology. We manufacture an extensive line of drainage and specialty catheters...