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EMGuideWire's Radiology Reading Room: Spontaneous Pneumothorax

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The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Spontaneous Pneumothorax and is brought to you by Elizabeth Olson, MD, and Janet Lorenz, NP.

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EMGuideWire's Radiology Reading Room: Spontaneous Pneumothorax

  1. 1. Spontaneous Pneumothorax Elizabeth Olson, MD & Janet Lorenz, NP Carolinas Medical Center & Levine Children’s Hospital Charlotte, North Carolina Michael Gibbs, MD, Faculty Editor The Chest X-Ray Mastery Project™
  2. 2. Disclosures  This ongoing chest X-ray interpretation series is proudly sponsored by the Emergency Medicine Residency Program at Carolinas Medical Center.  The goal is to promote widespread mastery of CXR interpretation.  There is no personal health information [PHI] within, and all ages have been changed to protect patient confidentiality.
  3. 3. Process • Many are providing clinical cases and presentations are then shared with all contributors on our departmental educational website. • Contributors from many Carolinas Medical Center departments, and now… Brazil, Chile, and Tanzania. • We will review a series of CXR case studies and discuss an approach to the diagnoses at hand: SPONTANEOUS PNEUMOTHORAX.
  4. 4. Visit Our Website www.EMGuidewire.com For A Complete Archive Of Chest X-Ray Presentations And Much More!
  5. 5. Airway Bones Cardiac Diaphragm Effusion Foreign body Gastric Hilum
  6. 6. It’s All About The Anatomy!
  7. 7. 18-Year-Old With Acute Pleuritic Chest Pain.
  8. 8. Spontaneous Pneumothorax 18-Year-Old With Acute Pleuritic Chest Pain.
  9. 9. Young Healthy Patient Presents With Pleuritic Chest Pain.
  10. 10. Left Spontaneous Pneumothorax Young Healthy Patient Presents With Pleuritic Chest Pain.
  11. 11. After Drainage Young Healthy Patient Presents With Pleuritic Chest Pain.
  12. 12. Healthy Young Female With Sudden Onset Right-Sided Pleuritic Chest Pain.
  13. 13. Spontaneous Pneumothorax Healthy Young Female With Sudden Onset Right-Sided Pleuritic Chest Pain.
  14. 14. 20-Year-Old Male Presents With Sharp Chest Pain And Shortness Of Breath.
  15. 15. Left Spontaneous Pneumothorax 20-Year-Old Male Presents With Sharp Chest Pain And Shortness Of Breath.
  16. 16. After Drainage Healthy Male Presents With Sharp Chest Pain And Shortness Of Breath.
  17. 17. Healthy Male Presents With Sharp Chest Pain.
  18. 18. Healthy Male Presents With Sharp Chest Pain. Right Spontaneous Pneumothorax
  19. 19. Healthy Male Presents With Sharp Chest Pain. After Drainage
  20. 20. Young, Healthy Male Experiences Acute Left-Sided Chest Pain While Running.
  21. 21. Young, Healthy Male Experiences Acute Left-Sided Chest Pain While Running. Left Spontaneous Pneumothorax
  22. 22. Young, Healthy Male Experiences Acute Left-Sided Chest Pain While Running. After Drainage
  23. 23. Sahn SA. NEJM 2000; 342:868-874. Classification Of Pneumothorax According To Cause Spontaneous 1°: No clinical lung disease 2°: A complication of clinically apparent lung disease Traumatic • Penetrating trauma • Blunt trauma Iatrogenic • Transthoracic needle aspiration • Central line placement • Thoracentesis • Lung biopsy
  24. 24. Primary Spontaneous Pneumothorax – although technically occurring in the absence of clinical lung disease, much more common in smokers (including marijuana smokers). Also more common in tall men. Secondary Spontaneous Pneumothorax – most frequently due to COPD (57%); other causes include asthma, PJP pneumonia, cystic fibrosis, malignancy, or TB. Bintcliffe, O, & Maskell, N (2014). Spontaneous pneumothorax. BMJ. 2014; 348, g2928. doi: 10.1136/bmj.g2928
  25. 25. NEJM 2000; 342:868-874.
  26. 26. Steven A. Sahn, MD, FCCP; for theACCP Pneumothorax Consensus Group† ovide explicit expert-based consensusrecommendationsfor the management of adultswith econdaryspontaneouspneumothoracesinanemergencydepartment andinpatient hospital se of opinion wasmade explicit by employing a structured questionnaire, appropriateness onsensus scores with a Delphi technique. The guideline was designed to be relevant to o make management decisionsfor the care of patientswith pneumothorax. isions for observation, chest tube placement, surgical interventions, and radiographic fectivenessof pneumothorax resolution, duration of and patient tolerance of care, and x recurrence. erature review from 1967 to January 1999 and Delphi questionnaire submitted in three a multidisciplinary physician panel. guideline development group determined by consensus the relevant outcomes to be developing the Delphi questionnaire. ms, and costs:The type and magnitude of benefits, harms, and costsexpected for patients e implementation. ions: Management decisions vary between patients with primary or secondary pneu- with observation of small pneumothoracesbeing appropriate only for primary pneumo- level of consensusvariesregarding the specific interventionsindicated, but agreement general principles of care. ecommendations were peer reviewed by physician experts and were reviewed by the lege of Chest Physicians (ACCP) Health and Science Policy Committee. on: The guideline recommendations will be published in printed and electronic form ion of synopsesfor patientsand health care providers. Contentsof the guideline will be into continuing medical education programs. e ACCP. (CHEST 2001; 119:590–602)
  27. 27. Management Of Spontaneous Pneumothorax (PNTX) Primary Spontaneous Pneumothorax: Stable1, small PNTX Observe 4-6 hours, repeat CXR, consider discharge with close F/U Stable1, large PNTX Needle or catheter aspiration or pigtail or chest tube insertion Unstable patient2 Immediate pigtail/chest tube, if delayed needle or finger thoracostomy Secondary Spontaneous Pneumothorax: Stable1, small PNTX Admit for observation with treatment(s) based on progression Stable1, large PNTX Pigtail or chest tube insertion Unstable patient2 Immediate pigtail/chest tube, if delayed needle or finger thoracostomy Steven A. Sahn, MD, FCCP; for theACCP Pneumothorax Consensus Group† ovide explicit expert-based consensusrecommendationsfor the management of adultswith econdaryspontaneouspneumothoracesinanemergencydepartment andinpatient hospital se of opinion wasmade explicit by employing a structured questionnaire, appropriateness onsensus scores with a Delphi technique. The guideline was designed to be relevant to o make management decisionsfor the care of patientswith pneumothorax. isions for observation, chest tube placement, surgical interventions, and radiographic fectivenessof pneumothorax resolution, duration of and patient tolerance of care, and x recurrence. erature review from 1967 to January 1999 and Delphi questionnaire submitted in three a multidisciplinary physician panel. guideline development group determined by consensus the relevant outcomes to be developing the Delphi questionnaire. ms, and costs:The type and magnitude of benefits, harms, and costsexpected for patients e implementation. ions: Management decisions vary between patients with primary or secondary pneu- with observation of small pneumothoracesbeing appropriate only for primary pneumo- level of consensusvariesregarding the specific interventionsindicated, but agreement general principles of care. ecommendations were peer reviewed by physician experts and were reviewed by the lege of Chest Physicians (ACCP) Health and Science Policy Committee. on: The guideline recommendations will be published in printed and electronic form ion of synopsesfor patientsand health care providers. Contentsof the guideline will be into continuing medical education programs. e ACCP. (CHEST 2001; 119:590–602)
  28. 28. Even Large Spontaneous PNTX May Not Require Intervention:
  29. 29. Conservative vs. Interventional Treatment • Multicenter, randomized, non-inferiority trial evaluating the management of moderate-to-large primary spontaneous pneumothoraces • 316 patients total, randomized to either interventional treatment (154 pts) or conservative treatment (162 pts) • Primary outcome: complete radiographic resolution within 8 weeks Brown SGA. Conservative versus interventional treatment for spontaneous pneumothorax. N Engl J Med. 2020 Jan 30; 382(5): 405-415. doi: 10.1056/NEJMoa1910775
  30. 30. Conservative vs. Interventional Treatment Interventional treatment: • Small-bore pigtail catheter (≤12 fr) inserted & placed to water seal • Repeat CXR at 1 hr. If resolved, drain clamped & patient observed x 4 hrs • If patient stable and repeat CXR without recurrence, drain removed and patient discharged • If not resolved on initial CXR or if recurrence of PNTX, patient admitted for further care Conservative treatment: • Observed for 4 hrs; discharged if stable + not requiring O2 + tolerating ambulation Brown SGA. Conservative versus interventional treatment for spontaneous pneumothorax. N Engl J Med. 2020 Jan 30; 382(5): 405-415. doi: 10.1056/NEJMoa1910775
  31. 31. Conservative vs. Interventional Treatment • Results suggested that conservative treatment was not inferior to interventional treatment • Conservative treatment had a lower risk of adverse event and serious adverse events • Interestingly, the conservative group also had a lower risk of recurrence of PNTX Brown SGA. Conservative versus interventional treatment for spontaneous pneumothorax. N Engl J Med. 2020 Jan 30; 382(5): 405-415. doi: 10.1056/NEJMoa1910775
  32. 32. Comparing Management Strategies • Systematic review and network meta-analysis • Evaluated 12 RCTs involving 781 patients. Compared needle aspiration, small-bore chest tube (≤ 14 F), or large-bore chest tube (≥ 14 F) in terms of effectiveness, efficiency, and safety • Primary outcome: “Immediate success” of intervention • Secondary outcomes: Efficiency (LOS) & safety (risk of complications) Mummad SR. Comparative effectiveness of interventions in initial management of spontaneous pneumothorax: A systematic review and a Bayesian network meta-analysis. Ann Emerg Med; 2020: 0(0), 1-15. https://doi.org/10.1016/j.annemergmed.2020.01.009
  33. 33. Comparing Management Strategies Immediate success: • A – Resolution of symptoms and radiographic resolution, sustained for 6-24 h in the needle aspiration group • B – Radiographic resolution, no air leak, and chest tube removal in < 7 days in either size chest tube groups • C – Ability to discharge patient from the ED in the needle aspiration and small-bore chest tube group Mummad SR. Comparative effectiveness of interventions in initial management of spontaneous pneumothorax: A systematic review and a Bayesian network meta-analysis. Ann Emerg Med; 2020: 0(0), 1-15. https://doi.org/10.1016/j.annemergmed.2020.01.009
  34. 34. Comparing Management Strategies • No difference in immediate success between large-bore chest tube, small-bore chest tube, or needle aspiration • Needle aspiration had similar rate of complications as small-bore chest tube; significantly lower odds of complications seen with needle aspiration than large-bore chest tube • Small-bore chest tube most likely to be effective; needle decompression safest • No benefit of large-bore chest tube over small-bore chest tubes in the management of symptomatic spontaneous PNTX Mummad SR. Comparative effectiveness of interventions in initial management of spontaneous pneumothorax: A systematic review and a Bayesian network meta-analysis. Ann Emerg Med; 2020: 0(0), 1-15. https://doi.org/10.1016/j.annemergmed.2020.01.009
  35. 35. If You Have Interesting Cases Of Spontaneous Pneumothorax, We Invite You To Send A Set Of Digital PDF Images And A Brief Descriptive Clinical History To: michael.gibbs@atriumhealth.org Your De-Identified Case(s) Will Be Posted On Our Education Website And You And Your Institution Will Be Recognized!

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