Intro and outro tracks are adapted from “I dunno” by grapes, featuring J Lang, Morusque.
Case Scenario: 16-year-old male with right-sided chest pain
CXR shows a moderate pneumothorax
Spontaneous pneumothoraces are more common in males, by about 3:1
There was no trauma
Symptoms are right-sided chest pain and mild shortness of breath, but with stable vital signs
Historical Management of Spontaneous Pneumothorax
Five years ago, management would have involved admission with placement of a chest tube, with possible CT Chest to evaluate for blebs
CT Chests are probably not beneficial in terms of changing treatment parameters or outcomes
http://bit.ly/2PpAZOo
A retrospective multi-center trial between Kansas City, Michigan, and Wisconsin showed that chest tubes work about 50% of the time, but the management of the chest tube after it was placed was too disparate to create an algorithm (i.e. some would leave it for one day, some would wait for the air leak to go away, some would test on water seal, etc.)
There has never been a lot of solid research information generated
Historically, a chest tube would have been placed and watched for at least 48 hours
If he had an air leak at 48 hours, he would go to the OR for VATS
If he did not have an air leak, the chest tube would have been placed to water seal for 24 hours prior to chest tube removal
What We Know Now
The failure rate of patients who get a chest tube and resolve is about 50%
Patients who get a chest tube, fail in the hospital, and then undergo VATS have a failure rate of 25-30%
Based on the multi-center study mentioned above, chest tube failures were consistent across institutions; chest tube management alone was not superior to VATS
The next question became how to identify the 50% of patients who will fail chest tube management
Option of Immediate VATS
Patients with immediate VATS have a 10-15% failure rate
Patients with a chest tube first and then undergo VATS have a 25-30% failure rate
Midwest Consortium
http://www.mwpsc.org/
This group of 11 hospitals agreed to look at management of spontaneous pneumothorax to decrease the pre-VATS phase for patients who appeared as if they were going to fail chest tube management
Patients who presented with spontaneous pneumothorax underwent initial aspiration alone
In adults, the Society of Thoracic Surgery recommends primary aspiration for spontaneous pneumothorax
Rationale of Aspiration
This management is predicated on two things:
The hole has probably already closed by the time they reach the hospital, so they are no longer leaking
Even if it recurs, there is a very low chance of a life-threatening spontaneous pneumothorax
Tension physiology in a spontaneous pneumothorax has not been described in the literature
In the retrospective study of three centers mentioned above, none of the 81 patients presented with tension physiology
Aspiration Study from Midwest Consortium
This study was presented at APSA 2019 but is not yet published
All patients (33 total) who presented with spontaneous pneumothorax underwent immediate aspiration, with a capped catheter left in place for six hours
If there was no recurrent pneumothorax on CXR after six hours, the catheter was removed
If there was a recurrent pneumothorax, then management was left to the discretion of the surgeon
50% (16/33) did not fail and were discharged home
50% (17/33) of the patients who underwent aspiration failed, which is consistent with chest tube management alone
12 of the 17 who failed had a chest tube placed; 83% (10/12) of these patients failed their chest tube (either required VATS or returned with a recurrent pneumothorax)
5 of the 17 went immediately to the OR for VATS; none of these five patients recurred
There are not enough numbers to make definitive conclusions, but there are enough to seriously consider whether placing a chest tube in a patient who has failed aspiration and then keeping them in the hospital for days is worthwhile, when the vast majority of them will fail
Algorithm from the Aspiration Study
All patients presenting with spontaneous pneumothorax should undergo aspiration
Patients with recurrent pneumothorax after six hours should undergo immediate VATS
Outcomes in Patients Discharged Home after Aspiration Alone
Of the 16 patients who passed the aspiration test, 44% (7/16) came back with a pneumothorax
The positive predictive value of the aspiration was 83%; the negative predictive value was 56%
If all patients were taken directly for VATS, 25-30% would receive an unnecessary operation
How would you counsel a family based on this study?
Aspiration is safe, and in some circumstances it is effective
It will allow us to identify if your child is at immediate risk for an ongoing pneumothorax
If they are aspirated and then recur, we would take them directly to the operating room for VATS…………
