How do you manage spontaneous Pneumos?

[Aloha Kid]

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Had a young girl last night, tall, skinny, lanky, with a 30% L sided pneumothorax. In the past I've put in plain chest tubes and admitted, or just admitted to CT surgery. For this case I had an older attending who wanted to try an anterior chest catheter placement w/ stop-cock air aspiration. If the 4 hours post procedure CXR showed her pneumo was resolved or less than 10% the plan was to discharge her home with a 6-8 hour follow up CXR thereafter.

The catheter placement into the L anterior chest wall went very well and she was comfortable throughout the entire procedure. It appeared a lot less painful than traditional lateral wall chest tubes. There was a tight seal and we were able to aspirate 720 ml of air. Unfortunately, the 4 hour post procedure CXR showed reaccumulation of air (20% pneumo). We then hooked the catheter to wall suction and admitted her to CT surgery.

The CT surgeon wasn't thrilled about our procedure, but he wasn't totally against it either. In his opinion, often times there is still a persistent air leak from a ruptured bleb that persists. These small catheters do no cause enough irritation and inflammatory changes like a normal chest tube to expedite sealing of the bleb and halting the internal air leak.

What's your thoughts?

 

[Hawkeye Kid]

I did this several months ago with one of our pulmonolgists while on ICU call and it worked great--we did it about 2am and the guy went home later that morning. I actually used this study from Annals to suggest it and the attending was all over it. Here's the abstract and link to the full text:

Volume 51, Issue 1, Pages 91-100.e1 (January 2008)

Management of Emergency Department Patients With Primary Spontaneous Pneumothorax: Needle Aspiration or Tube Thoracostomy?

Shahriar Zehtabchi, MD, Claritza L. Rios, MD


published online 01 October 2007.

Study objective
The emergency management of primary spontaneous pneumothorax is controversial. This evidence-based emergency medicine review evaluates the existing evidence about the efficacy and safety of needle aspiration in comparison to tube thoracostomy for management of primary spontaneous pneumothorax.

Methods
We searched MEDLINE, EMBASE, the Cochrane Library, and other databases. We selected studies for inclusion in the review if the authors stated that they had randomly assigned hemodynamically stable patients with no underlying lung disease to needle aspiration or tube thoracostomy. The outcome measures of interest included admission rate, length of hospital stay, recurrence rate, failure rate of the procedure, dyspnea score during or after the procedure, pain score during or after the procedure, and complications.

Results
Three randomized trials with acceptable quality standards met the inclusion criteria. There was no significant difference between needle aspiration and tube thoracostomy when outcomes of immediate failure, 1-week failure, risk of complication, and 1-year recurrence rate were measured. Only 2 trials reported the rate of hospitalization; needle aspiration was associated with lower rates of hospitalization in both trials: relative risks of 0.26 (95% confidence interval [CI] 0.17 to 0.39) and 0.51 (95% CI 0.36 to 0.74). Length of hospital stay was lower in the needle aspiration groups in all 3 trials, with mean differences of −2.15 days (95% CI −0.99 to −3.30), −2.10 days (95% CI −0.57 to −3.63), and −1.10 days (95% CI −2.28 to 0.08), respectively. Needle aspiration was associated with less analgesia requirement in one trial and lower pain scores in another.

Conclusion
The existing evidence indicates that needle aspiration is at least as safe and effective as tube thoracostomy for management of primary spontaneous pneumothorax. Additionally, needle aspiration carries the benefit of fewer hospital admissions and shorter length of hospital stay.

http://download.journals.elsevierhealth.com/pdfs/journals/0196-0644/PIIS0196064407007251.pdf

 

[a_ditchdoc]

If you are not comfortable with simple aspiration, the kits with the flutter valve work pretty well and seem perfect for spontaneous pneumos. Speaking from experience, it was a hell of a lot less painful than a large chest tube. I had a flutter valve placed for a pneumo and it worked great. I went home and against better judgment, resumed my normal activities with vigor. All was well until I awakend early one morning a bit short winded. My flutter valve had disconnected during my sleep and I had a 80% pneumo. The surgeon decided to insert a regular chest tube ad hospitalize me rather than to chance reattaching the valve and leaving the catheter in place. It hurt like hell.

If you have a choice, please try the flutter valve on spontaneous pneumos. Mine didn't work out, but I should have left it taped where it was rather than beside me. It leaves much less scarring as well, which is important for females. I am also very liberal with narcotics and sedatives when putting in chest tubes. It is no different to being stabbed in the chest slowly, with a blunt object, until it penetrates your chest cavity. This whole "Sorry, but it is gonna hurt either way" stuff is simply surgical bravado. We have ways to make the procedure more tolerable. Not doing so, when time and situation permits, is simply not practicing good medicine in my opinion.

On the flip side, I have had an attending not let me use a flutter valve because of lack of familiarity with the equipment: a long catheter, tubing, and a flutter valve.

 

[deleted109597]

Even if you don't want to use a flutter valve, if it is just a spontaneous pneumo we should be using Furman catheters. If you aren't pulling out blood or pus, 32-40 French is about 4000x too big for air molecules. It isn't like it is going to make the air come out faster or anything. Plus, you can always attach a valve to a Furman anyway.

 

[Aloha Kid]

Hawkeye Kid,

Thanks for the journal articles. I'll definitely take a look at them.

a_ditchdoc,

I definitely saw the flutter valve, just didn't know what exactly to do with it. The whole contraption looked a little difficult to tape to the chest wall and send a person home on as well.

 

[Carter0891]

The CT surgeon wasn't thrilled about our procedure, but he wasn't totally against it either. In his opinion, often times there is still a persistent air leak from a ruptured bleb that persists. These small catheters do no cause enough irritation and inflammatory changes like a normal chest tube to expedite sealing of the bleb and halting the internal air leak.

What's your thoughts?

What's a bleb?

 

[kungfufishing]

The one of these devices I've used has sort of a box attached to it, comes with a little trochar and a little tube. I like the idea of something much less awkward. If you are going to end up with a big apparatus anyway, just stick a 24Fr. in it. Anyone know the setup I'm talking about?

 

[bartleby]

There are several commercially available kits that have a 10 french "pigtail" catheter (the end coils when the trochar is removed like the aforementioned pig's tail) with a heimlich (flapper) valve which allows intrathoracic air to be expelled during exhalation but does not allow ingress of air during inspiration. I've had great success with these both with inpatient care (persistent leak, elderly, COPD comorbidity) and outpatient close followup. If you are aggressive about local anagesia with tubes this small (subcutaneous tissue down to pleura, periosteum of the rib you will approach and slip over), people report minimal discomfort during the procedure. Aside from the size of the tube, you avoid the most painful part of a large chest tube insertion by avoiding having to stretch the pleura when you pop through with the Kellys and bluntly enlarge your opnening.

One tip: even the 10 fr tubes go in much easier if you make a small nick in the anesthetised skin at the insertion site so the fenestrations don't snag on the epidermis.

The one of these devices I've used has sort of a box attached to it, comes with a little trochar and a little tube. I like the idea of something much less awkward.

 

[kungfufishing]

yes, I get all that, but do you know which kits have a less obtrusive valve apparatus? This is probably just the depth of my inexperience speaking, but I've seen the "box" type and one other which I did not place and am thus infamiliar. Totally agree with the rest of the post, I am just looking for something small, effective, and easy to stick to the chest for the spont. pneumo or (egad!) subclavian iatrogenic pneumo patient. Nice to have people who have done this longer than I have on SDN.