This presentation discusses treatment of spontaneous pneumothorax in emergency departments in light of recent evidence and new guidelines.

1. Spontaneous pneumothorax:
Evidence-update
Anne-Maree Kelly
February 2013

2. Permissions
 This presentation may be reproduced 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

3. Learning objectives
 To review current evidence-based
guidelines for management of
spontaneous pneumothorax
 To apply evidence-based decision-
making to cases of spontaneous
pneumothorax

4. Getting started
 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

5. Mike
 Aged 19
 Onset of pleuritic
chest pain
yesterday
 Mildly SOB on
exertion
 At rest, pulse 60,
O2 sat 98% on
room air

6. What would you do?
 A. 36G intercostal catheter and UWSD
 B. Small bore ICC and heimlich valve/
UWSD
 C. Aspirate
 D. Conservative management

7. Would this xray change your mind?
Same
symptoms and
vital signs

8. Epidemiology
 Primary spontaneous pneumothorax is
a disease of the young
◦ Peak incidence late teens/ twenties
 Male> Female
 Smoking is a major risk factor

9. Clinical features
 Chest pain: 90%
◦ Sharp, dull
 Dyspnoea- can be transient
 Presentation delayed > 24 hours in
>50% of patients
 Signs
◦ Resonant chest
◦ Reduced breath sounds
◦ Often subtle

10. Imaging
 Chest 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

11. A question of size?
 No international agreement
 More difficult with electronic images!
 Australia
◦ Small: <2 cm rim around lung (measured
at hilum)
 US
◦ Small: <3cm inter-pleural distance at apex

12. Treatment
 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.
◦ Cause of pneumothorax.

13. Emergent drainage
 Who?
◦ Patients with severe respiratory
compromise
◦ Patients with shock
 How?
◦ 14G IV catheter
◦ Small bore catheter (eg Cook’s) via
Seldinger technique
◦ Definitive treatment required

14. Minimal symptoms
 Evidence 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

15. Symptomatic
 Main indication for intervention is
presence of significant breathlessness
 Options
◦ Aspiration
◦ Catheter drainage

16. Aspiration
 Usually 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

17. Catheter drainage
 Small 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

18. 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

19. Recurrence
 Up to 50% after first pneumothorax
◦ Greatest risk in first year
 Up to 70% after subsequent
pneumothorax

20. 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

21. 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

22. Did you change your mind?
 Aged 19
 Onset of pleuritic
chest pain
yesterday
 Mildly SOB on
exertion
 At rest, pulse 60,
O2 sat 98% on
room air

23. Did you change your mind?
Same
symptoms and
vital signs

24. Spontaneous pneumothorax
If 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 drainage
Admit
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

25. An exercise in decision-
making
 Tim, aged 24
 Moderate primary spontaneous
pneumothorax on left (2cm rim)
 Symptoms> 24 hours
 Minimal symptoms
What would you do?

26. An exercise in decision-
making
 Tim, aged 24
 Moderate 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?

27. QUESTIONS
@kellyam_jec