Techniques and ProceduresAlternative Treatments of Pneumothorax
Introduction
Pneumothorax, the presence of air in the pleural space leading to loss of negative intrathoracic pressure, is a commonly encountered condition in the Emergency Department (ED). The process may be spontaneous, traumatic, or iatrogenic, and if there is increasing pressure in the pleural space, one may develop a pneumothorax with tension physiology. Spontaneous pneumothorax may be further differentiated into primary, occurring in patients without underlying lung disease, and secondary, involving patients with any of a wide variety of parenchymal diseases. Traditionally, tube thoracostomy has been used as the treatment for pneumothorax in the ED. There are, however, less-invasive management alternatives, specifically in treating primary spontaneous pneumothorax (PSP).
The incidence of PSP is thought to be as high as 18 per 100,000 in males and 6 per 100,000 in females (1). Risk factors for PSP include tall stature, thin body habitus, male gender, and smoking. There are also studies suggesting that pregnancy may be an additional risk factor, and a familial preponderance may be seen 2, 3. PSP has been shown to have lower rates of mortality and recurrence when compared to other types of pneumothorax (4). For this reason, more conservative treatment, which may lead to a decrease in resource utilization and the need for, or duration of, hospitalization, may be considered in PSP, as well as a few other select pneumothorax scenarios.
Alternatives to tube thoracostomy in the ED include observation, simple aspiration, and small-bore catheter insertion; each will be discussed below.
Section snippets
Estimation of Pneumothorax Size
To determine the most appropriate management, it may be necessary to first obtain a reasonable estimation of the size of the pneumothorax. The most definitive way of measuring pneumothorax size is by three-dimensional volume measurement using computed tomography (CT) imaging. However, in most cases of pneumothorax, CT imaging is not indicated or necessary, as it will likely not change management 5, 6. Therefore, routine estimation of pneumothorax size is often done using plain films. The
Conclusion
ED management of the stable patient with stable, atraumatic pneumothorax is continually evolving. These patients, and particularly those with primary spontaneous pneumothorax, may be treated with less invasive maneuvers and sometimes with no intervention at all. Many Emergency Physicians may be hesitant to utilize these techniques due to lack of experience or comfort. However, the literature supports that incorporating observation, simple aspiration, and small-bore catheter insertion with
References (30)
- et al.
Pneumothorax and pregnancy
Chest
(2007) - et al.
Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement
Chest
(2001) - et al.
Comparison between two methods for estimating pneumothorax size from chest X-rays
Respir Med
(2006) - et al.
Civilian spontaneous pneumothorax: treatment options and long term results
Chest
(1989) - et al.
Simple aspiration of spontaneous pneumothorax
Br J Dis Chest
(1981) The role of simple aspiration in the management of primary spontaneous pneumothorax
J Emerg Med
(2008)- et al.
Comparison of a large and small-calibre tube drain for managing spontaneous pneumothoraces
Respir Med
(2009) - et al.
Efficacy and complications of small-bore, wire-guided chest drains
Chest
(2006) - et al.
Complications of tube thoracostomy placement in the emergency department
J Emerg Med
(2011) - et al.
The thoracic vent. Clinical experience with a new device for treating simple pneumothorax
Chest
(1991)
The cost of treatment of spontaneous pneumothorax with the thoracic vent compared with conventional thoracic drainage
Chest
Outpatient treatment of spontaneous pneumothorax in a community hospital using a Heimlich flutter valve: a case series
J Emerg Med
Percutaneous aspiration versus tube drainage for spontaneous pneumothorax: systematic review and meta-analysis
Eur J Cardiothorac Surg
Familial spontaneous pneumothorax
Curr Opin Pulm Med
Spontaneous pneumothorax
N Engl J Med
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