When do you put in a chest tube for spontaneous pneumothorax?
Dr. Kristina Porada, PGY-1
Why do we care?
Spontaneous pneumothoraces affect >20,000 patients per year in the U.S. and account for ~$130,000,000 in health care expenditures
14.1 per 100,000 in population > 15 years old
Males > females
Most common cause of secondary spontaneous pneumothorax is COPD
Most common early physical exam findings = tachycardia
What does the textbook say?
2 goals of management: evacuate air from the pleural space and prevent recurrence
Primary spontaneous pneumothorax
Oxygen and observe for 4 hours
Repeat CXR prior to discharge
Follow up in 24-48 hours
Secondary spontaneous pneumothorax
Admission and observe
Needle aspiration if 1-2cm in size
Small chest tube or pigtail if >2 cm or failed simple aspiration
American College of Chest Physicians Consensus Statement
Primary Spontaneous Pneumothorax
Clinically stable with small pneumothorax
Observe in emergency department for 3-6 hours
Discharge home with 12-48 hour follow-up
Admit if unreliable follow-up
Clinically stable with large pneumothorax
Re-expansion via small-bone catheter or chest tube
Catheters or tubes attached to Heimlich valve or water seal
Clinically unstable with large pneumothorax
Chest tube
Water seal device without suction initially
Suction if lung doesn't expand
CT Chest
Routine use with first time pneumothorax
Possibly for further evaluation of pulmonary disorders
Secondary Spontaneous Pneumothorax
Clinically stable with small pneumothorax
Hospitalization
Consider chest tube
Clinically stable with large pneumothorax
Chest tube and admit
Clinically unstable with any size pneumothorax
Chest tube and admit
CT Chest
No clear recommendation after first occurrence of pneumothorax
ACCP v.s. British Thoracic Society
Literature Review
NEJM: Conservative vs. interventional treatment of spontaneous pneumothorax (2020)
■Conservative management is noninferior to interventional management for radiographic resolution of moderate-to-large primary spontaneous pneumothorax
–Spared 85% of patients from invasive intervention
–Fewer days in hospital or off from work
–Lower rates of surgery
–Lower risk of serious adverse events or pneumothorax recurrence
ERJ: Randomised comparison of needle aspiration and chest tube drainage in spontaneous pneumothorax (2017)
■Duration of hospital stay after needle aspiration is almost half the length of that for chest tube drainage (primary and secondary spontaneous PTX)
■Complication rate is negligible for needle aspiration compared to chest tube drainage
■No significant difference in 1 year recurrence rates
■Significant advantage for needle aspiration over chest tube drainage for immediate successes for both primary and secondary spontaneous PTX
So...size matters
Where we see a shift
■Conservative management of stable, mildly symptomatic, LARGE primary spontaneous pneumothorax
–Can be considered for patients < 50 years old
–Monitor for 4 hours in the ED with repeat CXR
–Stable patient with normal vitals, can ambulate comfortably à DC with repeat CXR in 24 hours
–Any increase in size warrants intervention
One more thought
■Is there a role for POCUS in the diagnosis over supine chest radiography?
–A topic for a different place and time
–But spoiler alert: if that place is the trauma bay, then yes
Clinical Implications
Attending Questions
■Do you ever order CT chest to follow up on pneumothorax seen on CXR? If so, under what circumstances?
■Do you have absolute contraindications for observation in the ED and discharge home regardless of the size of pneumothorax and clinical appearance of patient?
■Does your approach to pneumothorax change at all in children (age < 15)?
**References
■Rosen's Emergency Medicine: Concepts and Clinical Practice, 63, 839-848.e1
■https://emergencymedicinecases.com/management-spontaneous-pneumothorax/
■https://thorax.bmj.com/content/65/Suppl_2/ii18
■https://www.acepnow.com/article/whats-the-best-intervention-for-primary-spontaneous-pneumothorax/
■https://journal.chestnet.org/article/S0012-3692(15)38241-6/pdf
■https://erj.ersjournals.com/content/49/4/1601296
■https://www.nejm.org/doi/full/10.1056/NEJMoa1910775
■https://www.emrap.org/episode/ema2020november/abstract23chest