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Spontaneous pneumothorax:Evidence-updateAnne-Maree KellyFebruary 2013
Permissions This presentation may be reproduced inwhole or in part for educational purposes onthe condition that the foll...
Learning objectives To review current evidence-basedguidelines for management ofspontaneous pneumothorax To apply eviden...
Getting started Which of the following is the maindeterminant of ED therapeuticintervention in primary spontaneouspneumot...
Mike Aged 19 Onset of pleuriticchest painyesterday Mildly SOB onexertion At rest, pulse 60,O2 sat 98% onroom air
What would you do? A. 36G intercostal catheter and UWSD B. Small bore ICC and heimlich valve/UWSD C. Aspirate D. Conse...
Would this xray change your mind?Samesymptoms andvital signs
Epidemiology Primary spontaneous pneumothorax isa disease of the young◦ Peak incidence late teens/ twenties Male> Female...
Clinical features Chest pain: 90%◦ Sharp, dull Dyspnoea- can be transient Presentation delayed > 24 hours in>50% of pat...
Imaging Chest xray◦ Erect CXR is highly sensitive for clinicallyrelevant pnuemothorax◦ Expiratory film adds little and sh...
A question of size? No international agreement More difficult with electronic images! Australia◦ Small: <2 cm rim aroun...
Treatment Evidence base is NOT strong Factors to consider:◦ Type of pneumothorax: primary or secondary.◦ Clinical eviden...
Emergent drainage Who?◦ Patients with severe respiratorycompromise◦ Patients with shock How?◦ 14G IV catheter◦ Small bor...
Minimal symptoms Evidence supports conservativetreatment irrespective of xray findings Re-absorb at rate of 1.5-2.3%hemi...
Symptomatic Main indication for intervention ispresence of significant breathlessness Options◦ Aspiration◦ Catheter drai...
Aspiration Usually performed using a small catheter e.g.Cooks Aim is to convert a large pneumothorax to asmall one Succ...
Catheter drainage Small bore catheters (e.g. Cook’s) are aseffective as large catheters Success rate 65-95% Suction doe...
Surgery About 10% of patients require surgicalintervention Indications:◦ persistent air leak after 2-7 days◦ recurrent p...
Recurrence Up to 50% after first pneumothorax◦ Greatest risk in first year Up to 70% after subsequentpneumothorax
Revisiting Which of the following is the maindeterminant of ED therapeuticintervention in primary spontaneouspneumothorax...
Revisiting Which of the following is the maindeterminant of ED therapeuticintervention in primary spontaneouspneumothorax...
Did you change your mind? Aged 19 Onset of pleuriticchest painyesterday Mildly SOB onexertion At rest, pulse 60,O2 sat...
Did you change your mind?Samesymptoms andvital signs
Spontaneous pneumothoraxIf bilateral or haemodynamically unstable, proceed to catheter drainage•Age >50 and significant sm...
An exercise in decision-making Tim, aged 24 Moderate primary spontaneouspneumothorax on left (2cm rim) Symptoms> 24 hou...
An exercise in decision-making Tim, aged 24 Moderate primaryspontaneouspneumothorax onleft (2cm rim) Symptoms> 24hours...
QUESTIONS@kellyam_jec
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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.

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Treatment of spontaneous pneumothorax: Evidence-based update

  1. 1. Spontaneous pneumothorax:Evidence-updateAnne-Maree KellyFebruary 2013
  2. 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. 3. Learning objectives To review current evidence-basedguidelines for management ofspontaneous pneumothorax To apply evidence-based decision-making to cases of spontaneouspneumothorax
  4. 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. 5. Mike Aged 19 Onset of pleuriticchest painyesterday Mildly SOB onexertion At rest, pulse 60,O2 sat 98% onroom air
  6. 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. 7. Would this xray change your mind?Samesymptoms andvital signs
  8. 8. Epidemiology Primary spontaneous pneumothorax isa disease of the young◦ Peak incidence late teens/ twenties Male> Female Smoking is a major risk factor
  9. 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. 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. 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. 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. 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. 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. 15. Symptomatic Main indication for intervention ispresence of significant breathlessness Options◦ Aspiration◦ Catheter drainage
  16. 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. 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. 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. 19. Recurrence Up to 50% after first pneumothorax◦ Greatest risk in first year Up to 70% after subsequentpneumothorax
  20. 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. 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. 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. 23. Did you change your mind?Samesymptoms andvital signs
  24. 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. 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. 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. 27. QUESTIONS@kellyam_jec

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