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Pneumothorax Management
The document discusses the management of pneumothorax. It begins with an anatomy and pathophysiology review. Diagnosis methods including chest x-ray and CT scan are discussed. Management depends on size and symptoms, ranging from oxygen for small pneumothoraces to needle aspiration or chest drain for larger ones. Recent literature finds needle aspiration as effective as chest drains with fewer admissions. Outpatient management with pigtail catheters is shown to be successful in 78% of large pneumothoraces. Follow up by respiratory physicians until full resolution is recommended.
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Pneumothorax Management
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- 2. • Pathophysiology • Diagnosis •Brief review of management • Discussion of recent literature Introduction
- 3. • https://youtu.be/hjQupYskOZw?t=1678 • https://youtu.be/wDHOubwvRdg?t=1733 AnatomyRefresher Back to the 90’s with Robert Acland
- 4. • Air betweenparietal and visceral pleura Pathophysiology Traumatic: Perforation of parietal or visceral pleura Spontaneous: Rupture of sub- pleural bullae. Primary Secondary
- 5. • PA erectCXR: Sensitivity 83% 1 • CT chest: Much higher • Ultrasound: Sensitivity approaching 100%1 Diagnosis
- 6. Spontaneous pneumothorax –Management2 Boring
- 7. Spontaneous pneumothorax -Management Primary < 2 cm and clinically well Probable discharge with early follow up > 2 cm or unwell Needle/catheter aspiration Success? Generally all require admission <1cm – Oxygen 1-2cm – Needle/catheter aspiration >2cm / unwell – Small bore chest drain Secondary
- 8. • Needle Aspiration: •“Simple aspiration under LA with 14-16 G cannula, until resistance is felt, patient coughs excessively or over 2.5 litres withdrawn:”3 • Evidence that simple needle aspiration is just as effective as ICC insertion but leads to fewer hospital admissions and less analgesic requirements. 4 • Repeat CXR 6 hours later and discharge if successful Spontaneous pneumothorax - Management
- 9. • Management ofEmergency Department Patients With Primary Spontaneous Pneumothorax: Needle Aspiration or Tube Thoracostomy? Shahriar Zehtabchi, MD, , Claritza L. Rios, MD. Annals emergency medicine Volume 51, Issue 1, January 2008, Pages 91–100.e1 • Literature review of three prospective, randomised controlled trails • All three studies only including patients with primary spontaneous pneumothoracies • Same failure rates between both procedures at immediate, 1-week and 1 year time periods (Approximately 40%, 10% and 25% respectively) Needle aspiration or tube thoracostomy?4
- 10. • Approximately halfthe rate of hospital admissions for those receiving needle aspiration • Higher pain scores reported for those receiving tube thoracostomy • Also higher complication rates (tube blockage, infection, surgical emphysema) • No mention of tube thoracostomy size/type used – pigtail catheter or surgical chest drain ? • Not applicable for those with secondary spontaneous pneumothoracies Needle aspiration or tube thoracostomy?
- 11. • Retrospective studyfrom 2014 looking at outpatient management of both primary and secondary large pneumothoracies with pigtail catheters • 132 patients in study group • All discharged 2 hours post observation in ED following placement of pigtail catheter with 1-way valve fitted. No imaging done. • Followed up by outpatient respiratory team at day 2 • 78% success rate with outpatient management alone Ambulatory management of large spontaneous pneumothorax with pigtail catheters. Voisin F1, Sohier L2, Rochas Y2, Kerjouan M3, Ricordel C3, Belleguic C3, Desrues B3, Jouneau S4. Ann Emerg Med. 2014 Sep;64(3):222-8. doi: 10.1016/j.annemergmed.2013.12.017. Epub 2014 Jan 15.
- 12. Spontaneous pneumothorax -Management https://www.youtube.com/watch?v=jk19A8v7TtA Here’s how I insert a pigtail catheter
- 13. Spontaneous pneumothorax –Follow up 5 • Patients should be advised to return to hospital if increasing breathlessness develops. • All patients should be followed up by respiratory physicians until full resolution. (CXR 2-4 weeks post discharge) • Air travel should be avoided until >1 week after full resolution. • Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy
- 14. 1. Tinitinallis’ emergencymedicine 2. https://www.brit-thoracic.org.uk/document-library/clinical-information/pleural-disease/pleural-disease-guidelines- 2010/pleural-disease-guideline/ 3. http://lifeinthefastlane.com/ebm-spontaneous-pneumothorax/ 4. Ann Emerg Med. 2008 Jan;51(1):91-100, 100.e1. doi: 10.1016/j.annemergmed.2007.06.009. Epub 2007 Sep 29.Management of emergency department patients with primary spontaneous pneumothorax: needle aspiration or tube thoracostomy? Zehtabchi S1, Rios CL. 5. Ambulatory management of large spontaneous pneumothorax with pigtail catheters. Voisin F1, Sohier L2, Rochas Y2, Kerjouan M3, Ricordel C3, Belleguic C3, Desrues B3, Jouneau S4. Ann Emerg Med. 2014 Sep;64(3):222-8. doi: 10.1016/j.annemergmed.2013.12.017. Epub 2014 Jan 15. References
Editor's Notes
- #5 Bleb formation may be related to the degradation of elastic fibers in the lung induced by smoking. Inflammation-induced small airway obstruction increases pressure gradients between the lung interstitium and alveoli, causing air leakage into the interstitium and rupture into the pleural space.12
- #6 Bleb formation may be related to the degradation of elastic fibers in the lung induced by smoking. Inflammation-induced small airway obstruction increases pressure gradients between the lung interstitium and alveoli, causing air leakage into the interstitium and rupture into the pleural space.12
- #8 TABLE 71-1 Criteria for Stable Patient with Pneumothorax Respiratory rate <24 breaths/min No dyspnea at rest, speaks in full sentences Pulse >60 and <120 beats/min Normal blood pressure for patient Oxygen saturation >90% on room air Absence of hemothorax Size measured from Thoracic apex to lung cupola
- #13 TABLE 71-1 Criteria for Stable Patient with Pneumothorax Respiratory rate <24 breaths/min No dyspnea at rest, speaks in full sentences Pulse >60 and <120 beats/min Normal blood pressure for patient Oxygen saturation >90% on room air Absence of hemothorax
- #14 BTS 2010 Guidelines Criteria for Stable Patient with Pneumothorax Respiratory rate <24 breaths/min No dyspnea at rest, speaks in full sentences Pulse >60 and <120 beats/min Normal blood pressure for patient Oxygen saturation >90% on room air Absence of hemothorax