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Treatment of spontaneous pneumothorax: Evidence-based update
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Treatment of spontaneous pneumothorax: Evidence-based update

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

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

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  • 1. Spontaneous pneumothorax:Evidence-updateAnne-Maree KellyFebruary 2013
  • 2. Permissions This presentation may be reproduced inwhole or in part for educational purposes onthe condition that the following appears oneach slide:‘Reproduced with the permission ofProfessor Anne-Maree Kelly, JosephEpstein Centre for Emergency MedicineResearch @Western Health, Melbourne,Australia’@kellyam_jec
  • 3. Learning objectives To review current evidence-basedguidelines for management ofspontaneous pneumothorax To apply evidence-based decision-making to cases of spontaneouspneumothorax
  • 4. Getting started Which of the following is the maindeterminant of ED therapeuticintervention in primary spontaneouspneumothorax?◦ A. Pneumothorax size◦ B. Presence or absence ofbreathlessness◦ C. Previous spontaneous pneumothorax◦ D. Occupation
  • 5. Mike Aged 19 Onset of pleuriticchest painyesterday Mildly SOB onexertion At rest, pulse 60,O2 sat 98% onroom 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?Samesymptoms andvital signs
  • 8. Epidemiology Primary spontaneous pneumothorax isa 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 clinicallyrelevant 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) innon-trauma
  • 11. A question of size? No international agreement More difficult with electronic images! Australia◦ Small: <2 cm rim around lung (measuredat 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 ofapproximately 1.25 to 2.2% of the volume ofhemithorax per day.◦ Age. Evidence suggests that aspiration isless successful in patients aged over 50.◦ Cause of pneumothorax.
  • 13. Emergent drainage Who?◦ Patients with severe respiratorycompromise◦ Patients with shock How?◦ 14G IV catheter◦ Small bore catheter (eg Cook’s) viaSeldinger technique◦ Definitive treatment required
  • 14. Minimal symptoms Evidence supports conservativetreatment 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 ispresence 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 asmall one Success = rim <2cm and resolution ofbreathlessness without re-accumulation over 4-6hours 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 aseffective as large catheters Success rate 65-95% Suction does not improve outcome andshould be avoided Trocars should not be used
  • 18. Surgery About 10% of patients require surgicalintervention Indications:◦ persistent air leak after 2-7 days◦ recurrent pneumothoraces◦ airline pilots, frequent plane travelers anddivers◦ contralateral or bilateral pneumothoracesand◦ pregnancy
  • 19. Recurrence Up to 50% after first pneumothorax◦ Greatest risk in first year Up to 70% after subsequentpneumothorax
  • 20. Revisiting Which of the following is the maindeterminant of ED therapeuticintervention in primary spontaneouspneumothorax?◦ A. Pneumothorax size◦ B. Presence or absence ofbreathlessness◦ C. Previous spontaneous pneumothorax◦ D. Occupation
  • 21. Revisiting Which of the following is the maindeterminant of ED therapeuticintervention in primary spontaneouspneumothorax?◦ A. Pneumothorax size◦ B. Presence or absence ofbreathlessness◦ C. Previous spontaneous pneumothorax◦ D. Occupation
  • 22. Did you change your mind? Aged 19 Onset of pleuriticchest painyesterday Mildly SOB onexertion At rest, pulse 60,O2 sat 98% onroom air
  • 23. Did you change your mind?Samesymptoms andvital signs
  • 24. 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 pneumothoraxSize > 2cm or significantbreathlessness?Consider discharge with followupnext day and 1-2 weeklythereafter until resolutionSimple aspirationSuccess :- <3 litres aspirated AND- size < 2cm on xray 4 hours postaspiration AND- no significant breathlessnessCatheter drainageAdmitSize > 2cm or significant breathlessness?Simple aspirationSize <1cmNoNoYes*Yes NoYesYes NoSize <1cm YesNoAdmitHigh flow oxygen (unlessO2 sensitive)Observe minimum 24hoursNo* In some patients with a large pneumothorax but minimal symptomsconservative management may be appropriate
  • 25. An exercise in decision-making Tim, aged 24 Moderate primary spontaneouspneumothorax on left (2cm rim) Symptoms> 24 hours Minimal symptomsWhat would you do?
  • 26. An exercise in decision-making Tim, aged 24 Moderate primaryspontaneouspneumothorax onleft (2cm rim) Symptoms> 24hours Minimal symptoms Would that thatchange if: Tim had a previousipsilateralpneumothorax? Tim was a pilot?If so, what wouldyou do?
  • 27. QUESTIONS@kellyam_jec