When do you put in a chest tube for spontaneous pneumothorax?

Dr. Kristina Porada, PGY-1

Why do we care?

What does the textbook say?

2 goals of management: evacuate air from the pleural space and prevent recurrence

American College of Chest Physicians Consensus Statement

Primary Spontaneous Pneumothorax

Secondary Spontaneous 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)?