Spontaneous pneumothorax:Evidence-update
Anne-Maree KellyFebruary 2013
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in whole or in part for educational purposes on the condition that the following appears on each slide:
‘Reproduced with the permission of Professor Anne-Maree Kelly, Joseph Epstein Centre for Emergency Medicine Research @Western Health, Melbourne, Australia’
@kellyam_jec
Learning objectivesTo review current evidence-based
guidelines for management of spontaneous pneumothorax
To apply evidence-based decision-making to cases of spontaneous pneumothorax
Getting startedWhich 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
MikeAged 19Onset of pleuritic
chest pain yesterday
Mildly SOB on exertion
At rest, pulse 60, O2 sat 98% on room air
What would you do?A. 36G intercostal catheter and
UWSD
B. Small bore ICC and heimlich valve/ UWSD
C. Aspirate
D. Conservative management
Would this xray change your mind?
Same symptoms and vital signs
EpidemiologyPrimary spontaneous
pneumothorax is a disease of the young◦Peak incidence late teens/ twenties
Male> FemaleSmoking is a major risk factor
Clinical featuresChest pain: 90%
◦Sharp, dullDyspnoea- can be transientPresentation delayed > 24 hours
in >50% of patientsSigns
◦Resonant chest◦Reduced breath sounds◦Often subtle
ImagingChest xray
◦ Erect CXR is highly sensitive for clinically relevant pnuemothorax
◦ Expiratory film adds little and should be avoided
◦ Supine films little use
CT◦ Highly sensitive and can identify other
pathology
Ultrasound◦ Used in trauma but not widely accepted (yet)
in non-trauma
A question of size?No international agreementMore difficult with electronic
images!Australia
◦Small: <2 cm rim around lung (measured at hilum)
US◦Small: <3cm inter-pleural distance at
apex
TreatmentEvidence base is NOT strongFactors 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.
◦Cause of pneumothorax.
Emergent drainageWho?
◦Patients with severe respiratory compromise
◦Patients with shockHow?
◦14G IV catheter◦Small bore catheter (eg Cook’s) via
Seldinger technique◦Definitive treatment required
Minimal symptomsEvidence supports conservative
treatment irrespective of xray findings
Re-absorb at rate of 1.5-2.3% hemithorax/ day
Can be managed at home!Follow-up
◦Weekly◦Caveat: for early presenters (<24
hours), may be prudent to check next day
SymptomaticMain indication for intervention is
presence of significant breathlessness
Options◦Aspiration◦Catheter drainage
AspirationUsually performed using a small catheter e.g.
Cooks
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%
If you have aspirated >3 L, success unlikely◦ Connect to Heimlich valve or UWSD
Catheter drainageSmall bore catheters (e.g. Cook’s) are
as effective as large catheters
Success rate 65-95%
Suction does not improve outcome and should be avoided
Trocars should not be used
SurgeryAbout 10% of patients require
surgical interventionIndications:
◦persistent air leak after 2-7 days◦recurrent pneumothoraces◦airline pilots, frequent plane
travelers and divers◦contralateral or bilateral
pneumothoraces and◦pregnancy
RecurrenceUp to 50% after first
pneumothorax◦Greatest risk in first year
Up to 70% after subsequent pneumothorax
RevisitingWhich 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
RevisitingWhich 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
Did you change your mind?
Aged 19Onset of pleuritic
chest pain yesterday
Mildly SOB on exertion
At rest, pulse 60, O2 sat 98% on room air
Did you change your mind?
Same symptoms and vital signs
Spontaneous pneumothoraxIf bilateral or haemodynamically unstable, proceed to catheter drainage
•Age >50 and significant smoking history•Evidence of underlying lung disease on exam or CXR?
Primary pneumothorax Secondary pneumothorax
Size > 2cm or significant breathlessness?
Consider discharge with followup next day and 1-2 weekly thereafter until resolution
Simple aspiration
Success : - <3 litres aspirated AND - size < 2cm on xray 4 hours post
aspiration AND - no significant breathlessness
Catheter drainageAdmit
Size > 2cm or significant breathlessness?
Simple aspiration
Size <1cm
No
No
Yes*
Yes No
Yes
Yes No
Size <1cm Yes
No
Admit High flow oxygen (unless O2 sensitive)Observe minimum 24 hours
No
* In some patients with a large pneumothorax but minimal symptoms conservative management may be appropriate
An exercise in decision-makingTim, aged 24Moderate primary spontaneous
pneumothorax on left (2cm rim)Symptoms> 24 hoursMinimal symptoms
What would you do?
An exercise in decision-makingTim, aged 24Moderate primary
spontaneous pneumothorax on left (2cm rim)
Symptoms> 24 hours
Minimal symptoms
Would that that change if:
Tim had a previous ipsilateral pneumothorax?
Tim was a pilot?
If so, what would you do?
QUESTIONS
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