How do you manage your pneumothoraces?

[pinipig523]

How do you manage your ptx?

I have not seen too many spontaneous ptx because in residency, most of our ptx were assault/trauma related and we would just put a chest tube in every single one of them.

Now, I know the boards answer is 20% or less, you can observe and repeat cxr in 6h to see if it is expanding or stable. If no change then home and instructions that it will resolve about 4%/day.

Is that what you guys do too? When/what is your threshold at which you just put in a chest tube?

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[GeneralVeers]

How do you manage your ptx?

I have not seen too many spontaneous ptx because in residency, most of our ptx were assault/trauma related and we would just put a chest tube in every single one of them.

Now, I know the boards answer is 20% or less, you can observe and repeat cxr in 6h to see if it is expanding or stable. If no change then home and instructions that it will resolve about 4%/day.

Is that what you guys do too? When/what is your threshold at which you just put in a chest tube?

I had a sPTX myself when I was 20, and they didn't put in Chest Tube. I certainly wouldn't want one put in if it happened again. Thus if the patient is stable with good vital signs I wouldn't put one in. Most of these can go home if less than 20%.

 

[southerndoc]

Our pulmonologists are on-board with our door-to-door and door-to-floor metrics. So they will admit patients with small pneumothoraces for oxygen therapy (even if it's small) and repeat x-rays. If it's something that needs repeating (troponin, x-ray, etc.), our hospitalists, cardiologists, pulmonologists, etc. will admit for the repeat test and any further workup as needed.

If it's a spontaneous PTX that's large enough for a chest tube, then I use a Seldinger kit that has worked like a charm for me. I think it's a 14 Fr tube in it. Patients tolerate them very well (the last one I did, the patient couldn't believe it when I was finished because 2 weeks prior an ED doc had put in a 24 Fr chest tube the traditional way).

Basically it's like putting in a central line in the chest -- advance a large bore needle until you get return of air, thread the guide wire, make an incision, dilate, then introduce the catheter over the wire (usually I do this with the trocar until I'm in enough to get past the chest wall.

 

[dotcb]

Large - chest tube, admit.

If big enough to see on CXR, we'll probably put in a chest tube.

I've had good success diagnosing PTX based on pleural US, but the decision to put in a chest tube is a multifactorial decision, and I like to discuss it with the admitting team and show them the US before putting in a tube (if the patient is stable).

If small (Dx on CT but clinically insignificant), might do a 4-6 hr CXR and DC home w/ 24-48hr F/U if unchanged.

The literature on O2 for PTX is pretty thin.
http://regionstraumapro.com/post/399082315

 

[southerndoc]

The literature on O2 for PTX is pretty thin.
http://regionstraumapro.com/post/399082315

8 patients?

Plenty of things we do have "thin" research to support it.

 

[Rendar5]

spontaneous and moderate get a pigtail and a heimlich valve and d/c home or admit per the doctor's request. spontaneous and huge gets a regular Chest Tube. Spontaneous and small gets repeat CXR and NRB O2 for a few hours.

 

[TrustMe]

Our pulmonologists are on-board with our door-to-door and door-to-floor metrics. So they will admit patients with small pneumothoraces for oxygen therapy (even if it's small) and repeat x-rays. If it's something that needs repeating (troponin, x-ray, etc.), our hospitalists, cardiologists, pulmonologists, etc. will admit for the repeat test and any further workup as needed.

If it's a spontaneous PTX that's large enough for a chest tube, then I use a Seldinger kit that has worked like a charm for me. I think it's a 14 Fr tube in it. Patients tolerate them very well (the last one I did, the patient couldn't believe it when I was finished because 2 weeks prior an ED doc had put in a 24 Fr chest tube the traditional way).

Basically it's like putting in a central line in the chest -- advance a large bore needle until you get return of air, thread the guide wire, make an incision, dilate, then introduce the catheter over the wire (usually I do this with the trocar until I'm in enough to get past the chest wall.

I love these kits. They come in 2 sizes, 8.5 Fr and 14 Fr. Even the 8.5 Fr one is good for pneumothorax (since you're just evacuating air). For effusions (not blood), I usually put in the 14 Fr ones as well. As you said, goes in very smooth, patients tolerate it very well, and they don't end up with a scar on their skin (and psyche) from a large chest tube.

 

[Hamhock]

Anyone doing needle aspiration for acute, spontaneous PTX?

HH,

 

[Cerberus]

Anyone doing needle aspiration for acute, spontaneous PTX?

HH,

I'm also interested in hearing about this. I've had some very well appearing, healthy, young people with spontaneous pneumos that were too big to just ignore. I'd like to do try needle aspiration on these but don't know anyone who's done it.

 

[Hawkeye Kid]

Anyone doing needle aspiration for acute, spontaneous PTX?

HH,

I've done it a handful of times and it's worked well. It's fairly easy/quick to do, is pretty well-tolerated, and there's some literature supporting it. In my N ~ 5, I haven't had anyone require additional intervention.

 

[Hamhock]

and there's some literature supporting it.

http://www.annemergmed.com/article/S0196-0644(07)00725-1/abstract

This is what got me thinking about it.

Hawkeye: can you described exactly how you have done it? Catheter size? Location (axilla vs. anterior)? etc?

Thanks, HH

 

[Hawkeye Kid]

http://www.annemergmed.com/article/S0196-0644(07)00725-1/abstract

This is what got me thinking about it.

Hawkeye: can you described exactly how you have done it? Catheter size? Location (axilla vs. anterior)? etc?

Thanks, HH

Yeah, that's article I cite as well, though I started doing it a bit earlier after I read a different article.

I use a 16g, 3 1/2 in angiocath (the same one often used for needle decompression--nice because you can hook up a syringe to it) with a 60cc syringe and a 3-way stopcock. Put the patient at about 45-60 degrees for a bit before the procedure to make sure the air is in the right place. Insert the needle over the 2nd rib, mid-clavicular line, and once you aspirate air, advance the catheter and take the needle out. Then hook up the stopcock/syringe up to the catheter, aspirate into the syringe. Once the syringe is full, turn the stopcock off to the patient and push the air out the open port. Repeat until no longer able to aspirate, then take the catheter out. CXR and then CXR at 6 hours (I do the O2 in the interim, though I'm not convinced that it adds much). Could probably skip the immediate CXR, but it's nice to know how much of the PTX is left--I've always had some--to compare with the 6h CXR.

Like I said above, I've never had anyone who didn't "pass" the 6 hour obs period and every person I've done this to has tolerated it well. I think it helps to be liberal with the local anesthetic and to walk them through what you'll be doing (or make sure they don't watch) so they don't freak out when they see you coming at them with the needle.

Hope this helps. Happy to answer any other questions.