Author: Paul Trinquero, MD (EM Resident Physician, PGY-2, NUEM) // Edited by: Sushil Jain, MD (EM Resident Physician, PGY-4 NUEM) // Expert Commentary: Sean Smith, MD
Citation: [Peer-Reviewed, Web Publication] Trinquero P, Jain S (2017, January 3). Pneumothorax Part II: Management In The ED [NUEM Blog. Expert Commentary By Smith S]. Retrieved from http://www.nuemblog.com/blog/pneumothorax-management
While spontaneous pneumothorax is a common problem encountered by emergency physicians, there remains regular controversy regarding its appropriate management. The first decision point when evaluating a patient with a spontaneous, non-traumatic pneumothorax is to determine clinical stability. Roberts and Hedges defines a clinically stable patient as having ALL of the following: RR < 24, HR <120, normotensive, O2 sat >90% on RA, and ability to speak in whole sentences between breaths.
If the patient is unstable and tension physiology is suspected, urgent decompression is warranted (even in the absence of a confirmatory CXR because tension pneumothorax is a clinical diagnosis). Proceed with needle decompression in the 2nd intercostal space along the mid clavicular line, with a 14g angiocath, or if that fails, emergent pleural decompression using a 10 blade skin incision and blunt dissection with Kelly clamp to enter the pleural space (essentially the beginning steps to placing a surgical chest tube but performed in an emergency even if the kit is not readily available). Definitive treatment is placement of a surgical chest tube.
If the patient is clinically stable, proceed with further evaluation including history/physical exam and CXR. This will help to further categorize the pneumothorax and will aid in determining the appropriate treatment. There are four basic subcategories of spontaneous pneumothorax. Classification takes into account the presence or absence of underlying lung pathology and the size of the pneumothorax.
Management of Pneumothorax by Classification
Spontaneous pneumothorax is categorized as primary (no underlying lung disease---often young, tall males with apical blebs that can rupture) or secondary (presence of underlying lung disease such as COPD or cancer). Further subdivision is based on size, using 3cm from apex to cupola (the dome shaped rim of parietal pleura lining the superior chest wall) as the cutoff between small and large pneumothoraces per the criteria promoted by the American College of Chest Physicians.
Regardless of subclassification, all spontaneous pneumothoraces should be placed on supplemental oxygen, which helps with reabsorption.
1) Small, Primary: (less than 3cm apex to cupola distance, no underlying lung disease).
These patients can be observed in emergency department (ED) for 3 to 6 hrs and then discharged home if repeat CXR excludes progression (good consensus of evidence). They should have a reliable plan in place for follow up within 12-48hrs for repeat CXR. Admission can be considered for patients with an unreliable plan for follow up. On the other hand, if the repeat CXR shows progression of the pneumothorax, definitive management is indicated and they should be treated the same way as a patient with a large primary pneumothorax. Notably, symptom duration >24 hrs does not alter recommendations.
2) Large, Primary: (greater than 3cm, no underlying lung disease).
These patients need a re-expansion procedure. There is good evidence that for simple, non-traumatic pneumothorax (ie no concurrent hemothorax or effusion), a smaller caliber pigtail catheter (8.5-14 French) placed using a seldinger technique is just as effective as a large caliber surgical chest tube. In fact, the American College of Chest Physicians recommends the use of small-bore catheters for this indication. After placement of a chest tube however, there are conflicting opinions regarding disposition. The traditional approach is for these patients to be admitted for observation while attached to a water seal device such as the PleurEvac. Patients would then undergo repeat CXR, potentially a clamp trial, and eventual removal of the tube after sufficient re-expansion. However, a large case series in France that was published in the Annals of Emergency Medicine in 2014 demonstrates great outcomes for patients with a large spontaneous pneumothorax who were managed with pigtail catheters and discharged from the ED with a one-way valve. The one-way valve (Heimlich valve) serves the same function as the PleurEvac system in that it allows continued escape of air from the pleural space but prevents outside air from entering. This device not only aids in continued re-expansion over time but also protects against tension physiology because of the escape passage it affords. Because the device is small, it allows patients essentially full mobility with only minimal discomfort.
3) Small, Secondary: (less than 3cm, underlying lung disease)
These patients should likely be hospitalized (good consensus of evidence per Roberts and Hedges) rather than having a trial of ED observation (like the patients with small primary pneumothorax). Their underlying lung disease puts them at higher risk than the otherwise healthy patient. They can either be observed as an in-patient (with repeat CXR to determine whether the pneumothorax is expanding or resolving) or treated immediately with chest tube re-expansion. This decision depends on the extent of the patient's symptoms and course of the pneumothorax. If the patient is symptomatic it seems reasonable to proceed with re-expansion given that it may provide relief of symptoms. If the patient is asymptomatic and resistant to the procedure, it may be reasonable to admit for observation and repeat CXR before committing to a chest tube.
4) Large, Secondary: (larger than 3cm, underlying lung disease)
These patients need both chest tube re-expansion and hospitalization (very good consensus of evidence per Roberts and Hedges). Even though the French study cited above does demonstrate good outcomes for the small percentage of secondary pneumothorax patients who were included in the study population, the general consensus is to proceed with more caution in these patients with underlying lung disease. The simplest and probably safest approach would be to proceed with chest tube insertion by Seldinger technique for immediate re-expansion and then admit to the hospital for observation.
I very much enjoyed your discussion of spontaneous pneumothorax management.
An important consideration is whether it is the patient’s first or a recurrent spontaneous pneumothorax. After a first spontaneous pneumothorax, there is an estimated 30-40% risk of recurrence. Therefore, for patients with a first spontaneous pneumothorax that proves difficult to manage (e.g., persistent air leak, respiratory failure), consultation with Thoracic Surgery is valuable to consider VATS pleurodesis. I would also consider early surgical consultation for patients with occupations that require frequent travel to altitude (e.g., pilots) or depth (e.g., divers). If a patient presents to the emergency department with a recurrent spontaneous pneumothorax, I would recommend admission for surgical consultation. Initial management in the emergency department for a recurrent spontaneous pneumothorax follows similar principles as you describe. If the emergency physician places a chest tube, it can later be used for instillation of a chemical sclerosing agent (e.g., talc or doxycycline) if there is good expansion and no persistent leak. However, chest tube pleurodesis is generally reserved for patients who are poor operative candidates or who decline VATS after surgical consultation and discussion.
I agree that data are growing to support using smaller bore chest tubes. Patients requiring mechanical ventilation may benefit from a larger tube, although this is not an absolute teaching. The seldinger technique can still be used to place a large tube (including 28 – 36Fr sizes) if the proper kit is available with larger dilators. This makes placement easier for the patient compared to surgical dissection.
Thank you for the opportunity to participate in your great discussion.
Sean B. Smith, MD
Interventional Pulmonology; Pulmonary and Critical Care Medicine; Northwestern Medicine
Other Posts You May Enjoy
- Adams, J., Manthey, D., Nicks, B. (2013). Pneumothorax. Emergency medicine: Clinical Essentials. Philadelphia, Pa: Elsevier/ Saunders. Pages 423-430.
- Kirsh, T & Sax J (2013). Tube Thoracostomy. Roberts And Hedges' clinical procedures in emergency medicine. Philadelphia, PA: Elsevier/Saunders. Pages 189-211.
- Marquette, C. (2006). Simplified stepwise management of primary spontaneous pneumothorax: a pilot study. European Respiratory Journal, 27(3), 470-476. http://dx.doi.org/10.1183/09031936.06.00104905
- Voisin, F., Sohier, L., Rochas, Y., Kerjouan, M., Ricordel, C., & Belleguic, C. et al. (2014). Ambulatory Management of Large Spontaneous Pneumothorax With Pigtail Catheters. Annals Of Emergency Medicine, 64(3), 222-228. http://dx.doi.org/10.1016/j.annemergmed.2013.12.017