First-time Spontaneous Pneumothorax Management with Simple Aspiration
Search Strategy: Since this is a therapy question, you first turn to the Cochrane Database of Systematic Reviews and immediately locate a Cochrane Review from 2007. You also search Annals of Emergency Medicine’s Evidence Based Emergency Medicine section of high-quality pre-appraised EM-germane topics (click on the pre-appraised resources list then #16 Thoracic-Respiratory Disorders) and quickly locate a review by Zehtabchi on this exact topic which has identified three prior randomized controlled trials (RCT’s) on the topic. To ensure that more recent trials have not been published, you conduct a PUBMED Clinical Query (broad/sensitive) for therapy using the search term “spontaneous pneumothorax” and combine this search with “needle” yielding 28 citations but no further RCT’s are identified. Finally, a conservative colleague hands you another article detailing simple observation rather than any decompression.
Dr. Bausano is acting up again in TCC. During a typically busy October shift, you’ve lost (or won?) the “lucky” EM1 coin toss and now sit in EM1 wondering what is going on in TCC as you evaluate innumerable medical and psychiatric complaints. The charge nurse calls informing you that a stable spontaneous pneumothorax patient has been “refused” by Dr. B and will be placed into your pod. Your heart rate begins to rise as you contemplate something other than starting an IV, draining a knee, or a lumbar puncture.
The tall, thin patient notes sudden onset sharp right-sided chest pain beginning 3-hours ago. He appears comfortable and has completely normal vital signs (120/80, 64, 14, 36.8, 100% on room air) without any evidence of tension pneumothorax. Chest x-ray identifies a large right-sided pneumothorax without hemothorax. You pick up the phone to notify Surgery that a chest tube will be placed and begin setting up the Thal-Quick. Suddenly, your scholarly junior resident suggests that simple drainage or even observation without drainage may suffice in lieu of the standard chest tube. Breaking away from the fascination of EM1, you decide to efficiently search the literature.
Population: Hemodynamically stable Emergency Department patients with first-time (primary) isolated spontaneous pneumothorax
Intervention: Simple aspiration or no aspiration + observation
Comparison: Traditional tube thoracostomy
Outcome: Incidence of tension pneumothorax, ED and hospital length-of-stay, procedural complication rates, patient satisfaction, ED recidivism
First years: Manual aspiration versus chest tube drainage in first episodes of primary spontaneous pneumothorax: A multicenter, prospective, randomized pilot study, Am J Respir Crit Care Med 2002; 165: 1240-1244. (http://pmid.us/11991872)
Article 1: Manual Aspiration versus Chest Tube Drainage in First Episodes of Primary Spontaneous Pneumothorax: A Multicenter, Prospective, Randomized Pilot Study, Am J Resp Crit Care Med 2002; 165: 1240-1244
Article 2: Aspiration versus tube drainage in primary spontaneous pneumothorax: a randomised study, Eur Respir J 2006; 27: 477-482
Article 3: Outcomes of Emergency Department Patients Treated for Primary Spontaneous Pneumothorax, Chest 2008; 134: 1033-1036
Article 4: Simple aspiration versus intercostal tube drainage for primary spontaneous pneumothorax in adults, Cochrane Database Syst Review 2007; Issue 1. Art No. CD004479
The Succinct Answer
Over 20,000 primary spontaneous pneumothorax cases occur in the US each year costing $130 million annually. In spontaneous pneumothorax patients, any options to reduce unnecessary hospitalizations while relieving patient procedural-related discomfort would be mutually beneficial to patient’s, providers, and taxpayers. As suggested by two recent EM reviews (Chan 2008, Zehtabchi 2008), simple aspiration of first-episode, non-traumatic pneumothorax patients may be one opportunity to do so. Appearing in the medical literature since at least the 1980’s (Obeid 1985, Delius 1989, Devanand 2004, Kelly 2007) simple aspiration is not a new concept, but has yet to garner wide-spread acceptance. Chest tubes are not benign. Potentially fatal penetration of major organs or blood vessels have been reported with both intercostal tube drainage (Daly 1985; Miller 1987; Symbas 1989; Iberti 1992) and simple aspiration (Rawlins 2003). Other reported complications of intercostal tube drainage include pleural cavity infection (empyema reported incidence of 1%; Chan 1997) and surgical emphysema (Maunder 1984)”. Surgical RCT’s are rare and difficult to conduct (Lee 2009) and some have argued for randomization based upon surgical expertise (Devereaux 2005) to incorporate the impact of unrecognized/unmeasured attributes of specialty-specific care on patient-important outcomes. Therefore, the current evidence is an uncommon, invaluable tool by which to guide surgical management of a unique patient population.
Belgian patients with acute first-time spontaneous pneumothorax (PTX) managed with manual aspiration (MA) have equivalent immediate, 1-week, and 1-year success rates as those receiving traditional chest tubes. While 40% of MA will require a chest tube nonetheless, the remaining 60% can have PTX care simplified with presumably less painful aspiration while simultaneously decreasing admission rates and hospital length of stay. Similarly the Kuwaiti study demonstrated that simple aspiration of stable, uncomplicated, isolated first-episode primary spontaneous PTX offers equivalent immediate success rates (62% SA vs. 68% chest tube) without increased early recurrence or adverse consequences. Using this method could avoid 74% of admissions thereby reducing lost work days and iatrogenic complications. Future trials conducted with an appropriate a priori power analysis to confidently conclude equivalence should also assess patient satisfaction parameters, clinician learning curves, acceptability, and procedural times as well as cost-effectiveness. In addition, the Australian chart review suggested that small pneumothoraces in young males might safely be managed with observation alone, offering sufficient clinical equipoise to justify inclusion of an observation arm in subsequent prospective PTX trials.