Pneumothorax ============ þ Is aspiration OK? - Probably. [Gaudio, M. and J. W. Hafner (2009). "Simple Aspiration Compared to Chest Tube Insertion in the Management of Primary Spontaneous Pneumothorax." Annals of emergency medicine 54(3): 458-460]. BTS Guidelines for PTX - Strong emphasis should be placed on the relationship between the recurrence of pneumothorax and smoking in an effort to encourage patients to stop smoking. [B] - Expiratory chest radiographs are not recommended for the routine diagnosis of pneumothorax. [B] - A lateral chest or lateral decubitus radiograph should be performed if the clinical suspicion of pneumothorax is high, but a PA radiograph is normal. [B] - CT scanning is recommended when differentiating a pneumothorax from complex bullous lung disease, when aberrant tube placement is suspected, and when the plain chest radiograph is obscured by surgical emphysema. [C] - The clinical history is not a reliable indicator of pneumothorax size. [C] - The previous classification of the size of a pneumothorax tends to underestimate its volume. In these new guidelines the size of a pneumothorax is divided into "small" or "large" depending on the presence of a visible rim of <2 cm or >2 cm between the lung margin and the chest wall. - Observation should be the treatment of choice for small closed pneumothoraces without significant breathlessness. [B] - Patients with small (<2 cm) primary pneumothoraces not associated with breathlessness should be considered for discharge with early outpatient review. These patients should receive clear written advice to return in the event ofworsening breathlessness. [B] - If a patient with a pneumothorax is admitted overnight for observation, high flow (10 l/min) oxygen should be administered, with appropriate caution in patients with COPD who may be sensitive to higher concentrations of oxygen. [B] - Breathless patients should not be left without intervention regardless of the size of the pneumothorax on a chest radiograph. [C] - Simple aspiration is recommended as first line treatment for all primary pneumothoraces requiring intervention. [A] - Simple aspiration is less likely to succeed in secondary pneumothoraces and, in this situation, is only recommended as an initial treatment in small (<2 cm) pneumothoraces in minimally breathless patients under the age of 50 years. [B] - Patients with secondary pneumothoraces treated successfully with simple aspiration should be admitted to hospital and observed for at least 24 hours before discharge. [C] - If simple aspiration or catheter aspiration drainage of any pneumothorax is unsuccessful in controlling symptoms, then an intercostal tube should be inserted. [B] - Intercostal tube drainage is recommended in secondary pneumothorax except in patients who are not breathless and have a very small (<1 cm or apical) pneumothorax. [B] - A bubbling chest tube should never be clamped. [B] - A chest tube which is not bubbling should not usually be clamped. [B] - If a chest tube for pneumothorax is clamped, this should be under the supervision of a respiratory physician or thoracic surgeon, the patient should be managed in a specialist ward with experienced nursing staff, and the patient should not leave the ward environment. [C] - If a patient with a clamped drain becomes breathless or develops subcutaneous emphysema, the drain must be immediately unclamped and medical advice sought. [C] - There is no evidence that large tubes (20-24 F) are any better than small tubes (10-14 F) in the management of pneumothoraces. The initial use of large (20-24 F) intercostal tubes is not recommended, although it may become necessary to replace a small chest tube with a larger one if there is a persistent air leak. [B] - Pneumothoraces which fail to respond within 48 hours to treatment should be referred to a respiratory physician. [C] - Suction to an intercostal tube should not be applied directly after tube insertion, but can be added after 48 hours for persistent air leak or failure of a pneumothorax to re-expand. [B] - High volume, low pressure (-10 to -20 cm H2O) suction systems are recommended. [C] - Patients requiring suction should only be managed on lung units where there is specialist medical and nursing experience. [C] - Chemical pleurodesis can control difficult or recurrent pneumothorax [A] but should only be attempted if the patient is either unwilling or unable to undergo surgery. [B] - Medical pleurodesis for pneumothorax should be performed by a respiratory specialist. [C] - In cases of persistent air leak or failure of the lung to re-expand, the managing respiratory specialist should seek an early (3-5 days) thoracic surgical opinion. [C] - Open thoracotomy and pleurectomy remains the procedure with the lowest recurrence rate for difficult or recurrent pneumothoraces. Minimally invasive procedures, thoracoscopy (VATS), pleural abrasion, and surgical talc pleurodesis are all effective alternative strategies. - Surgical chemical pleurodesis is best achieved with 5 g sterile talc. Side effects such as ARDS and empyema are reported but rare. [A] - Patients discharged without intervention should avoid air travel until a chest radiograph has confirmed resolution of the pneumothorax. [C] [text recommends recheck CXR in 2 weeks --KC] - Diving should be permanently avoided after a pneumothorax, unless the patient has had bilateral surgical pleurectomy. [C] - Primary pneumothorax patients treated successfully by simple aspiration should be observed to ensure clinical stability before discharge. Secondary pneumothorax patients who are successfully treated with simple aspiration should be admitted for 24 hours before discharge to ensure no recurrence. [C] - Early and aggressive treatment of pneumothoraces in HIV patients, incorporating intercostal tube drainage and early surgical referral, is recommended. [B] "There are several reports that up to 25% of spontaneous pneumothoraces in large urban settings with a high prevalence of HIV infection are AIDS related; 2-5% of AIDS patients will develop a pneumothorax. Pneumocystis carinii infection should be considered as the most likely aetiology in any HIV positive patient who develops a pneumothorax, although the administration of aerosolised pentamidine has also been suggested as an independent risk factor." "Such is the relationship between AIDS related pneumothorax and the presence of P carinii that the occurrence of pneumothorax in AIDS patients is considered an indicator of treatment for active P carinii infection." - Early and aggressive treatment of pneumothoraces in cystic fibrosis is recommended. [C] - Surgical intervention should be considered after the first episode, provided the patient is fit for the procedure. [C] - If tension pneumothorax is present, a cannula of adequate length should be promptly inserted into the second intercostal space in themid clavicular line and left in place until a functioning intercostal tube can be positioned. [B] [Henry, M., T. Arnold, et al. (2003). "BTS guidelines for the management of spontaneous pneumothorax." Thorax 58 Suppl 2: ii39-52.] þ Determining size of PTX: - Measure, on PA view, three interpleural distances: + Maximum apical interpleural distance (vertical) + interpleural distance at midpoint of upper half of lung (horizontal) + interpleural distance at midpoint of lower half of lung (horizontal) Divide by three, then use this table: Avg interpleural distance, cm PTX size, % 0.5 10% 1 14% 1.5 17.5% 2 22.5% 2.5 27% 3 31% 3.5 36% 4 40% 4.5 45% 5 48% Magic number is 4 cm; those less than 40% can be aspirated. þ Epidemiology of spontaneous PTX - most common in neonatal period; ? due to patchy atelectasis - spontaneous PTX most common in thin, tall, men who abuse tobacco. þ Natural History of PTX - Resorption rate is 1.25% of the intrapleural volume per day. Therefore, a 20% pneumothorax will reabsorb in about 16 days. Ref: Rosen 3rd ed. p 1128. þ Treatment of PTX - Breathing 100% oxygen may speed resolution. This occurs by lowering the alveolar nitrogen partial pressure, causing an increased gradient between the pleural and alveolar air barrier. Ref: Rosen 3rd ed. p 1128. þ Catamenial pneumothorax - from endometriomas under diaphragm - comes with menses