Spontaneous pneumothorax:Evidence-update

Anne-Maree KellyFebruary 2013

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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’

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Learning objectivesTo review current evidence-based

guidelines for management of spontaneous pneumothorax

To apply evidence-based decision-making to cases of spontaneous pneumothorax

Getting startedWhich 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

MikeAged 19Onset of pleuritic

chest pain yesterday

Mildly SOB on exertion

At rest, pulse 60, O2 sat 98% on room air

What would you do?A. 36G intercostal catheter and

UWSD

B. Small bore ICC and heimlich valve/ UWSD

C. Aspirate

D. Conservative management

Would this xray change your mind?

Same symptoms and vital signs

EpidemiologyPrimary spontaneous

pneumothorax is a disease of the young◦Peak incidence late teens/ twenties

Male> FemaleSmoking is a major risk factor

Clinical featuresChest pain: 90%

◦Sharp, dullDyspnoea- can be transientPresentation delayed > 24 hours

in >50% of patientsSigns

◦Resonant chest◦Reduced breath sounds◦Often subtle

ImagingChest 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

A question of size?No international agreementMore difficult with electronic

images!Australia

◦Small: <2 cm rim around lung (measured at hilum)

US◦Small: <3cm inter-pleural distance at

apex

TreatmentEvidence base is NOT strongFactors 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.

Emergent drainageWho?

◦Patients with severe respiratory compromise

◦Patients with shockHow?

◦14G IV catheter◦Small bore catheter (eg Cook’s) via

Seldinger technique◦Definitive treatment required

Minimal symptomsEvidence 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

SymptomaticMain indication for intervention is

presence of significant breathlessness

Options◦Aspiration◦Catheter drainage

AspirationUsually 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

Catheter drainageSmall 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

SurgeryAbout 10% of patients require

surgical interventionIndications:

◦persistent air leak after 2-7 days◦recurrent pneumothoraces◦airline pilots, frequent plane

travelers and divers◦contralateral or bilateral

pneumothoraces and◦pregnancy

RecurrenceUp to 50% after first

pneumothorax◦Greatest risk in first year

Up to 70% after subsequent pneumothorax

RevisitingWhich 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

RevisitingWhich 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

Did you change your mind?

Aged 19Onset of pleuritic

chest pain yesterday

Mildly SOB on exertion

At rest, pulse 60, O2 sat 98% on room air

Did you change your mind?

Same symptoms and vital signs

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 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 drainageAdmit

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

An exercise in decision-makingTim, aged 24Moderate primary spontaneous

pneumothorax on left (2cm rim)Symptoms> 24 hoursMinimal symptoms

What would you do?

An exercise in decision-makingTim, aged 24Moderate 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?

QUESTIONS

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