Treatment of spontaneous pneumothorax is controversial. Are we treating the patient or the xray. See the latest evidence and decide for yourself.

1. SPONTANEOUS PNEUMOTHORAX:
ARE WE TREATING THE CXR OR THE
PATIENT?
January 2015
@kellyam_jec

2. 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

3. Conflicts of interest
 None to declare

4. Objectives
 To review current evidence-based
guidelines for management of
spontaneous pneumothorax
 To discuss the practical challenges in
managing spontaneous
pneumothorax

5. 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

6. 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

7. 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

8. Would this xray change your
mind?
Same history,
symptoms and
vital signs

9. 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

10. 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.

11. 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

12. 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

13. 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
Aspiration

14. International variation in
opinions
Region/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 conservative
Wales: 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

15. International variation in
practice
Country/
Region
Size Year
of
repor
t
Conservati
ve
Aspiratio
n
Pleural
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.

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. Symptomatic
 Main indication for intervention is
presence of significant
breathlessness
 Options
 Aspiration
 Catheter drainage
 Small bore
 Large bore
 Pigtail catheters / similar

25. 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%

26. 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

27. 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

28. 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).

29. 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

30. 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

31. Ambulatory management
options
Country/
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 rate
Singapore: 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.

32. 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

33. Recurrence
 Up to 50% after first pneumothorax
 Greatest risk in first year
 Up to 70% after subsequent
pneumothorax

34. Revisiting
 Which of the following is 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

35. Revisiting
 Which of the following is the main
determinant of ED therapeutic
intervention in primary spontaneous
pneumothorax?
 A. Pneumothorax size
 B. Presence or absence of
breathlessness
 C. Previous spontaneous
pneumothorax
 D. Occupation

36. 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

37. Did you change your mind?
Same history,
symptoms and
vital signs

38. Did you change your mind?
Same history, symptoms
and vital signs
I would treat both of
these conservatively
as outpatients

39. 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?

40. Question #1
 No intervention needed in ED
 Refer to thoracic surgery team for
definitive procedure (can be as
outpatient)

41. Question #1a
 Same history
 Pneumothorax ~70% and significant
breathlessness
 What should be done?

42. 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

43. Question #2
 Can I send a patient home with a
pigtail (similar) catheter and one
way valve in situ?

44. Question #3
 Is it safe to observe (treat
conservatively) a young patient
with large first PSP who has
minimal symptoms?

45. Question #3
 The evidence says ‘YES’
 Require:
 Sensible patient
 Access to appropriate followup
 Means of return to hospital if gets worse

46. Question #4
 What advice should I give about
work, flying and return to sport?

47. 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

48. Question #5
 Are there trials comparing
aspiration / small bore catheter
management with traditional large
bore pleural catheter management
for clinically significant outcomes?

49. Question #5
 Clinically significant outcomes
 Requirement for hospital admission
 Requirement for secondary procedure
 Requirement for surgery
 Recurrence

50. 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

51. Thankyou @kellyam_jec

52. 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

53. 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

54. What is in it for me?
 Taste of research
 Opportunity to be published
 Opportunity to present at local / national
conferences