Videos in clinical medicine. Needle aspiration of primary spontaneous pneumothorax

Spontaneous Pneumothorax: Controversies in Treatment

The Research to Practice column critiques a current research article and translates the findings, in the context of a case, to a practice change within emergency settings. This article reviews the findings of a randomized controlled trial conducted by A. Theille et al. (2017) comparing the use of needle decompression versus chest tube insertion for management of spontaneous pneumothorax. The study found that use of needle aspiration was safe and effective and was associated with fewer procedure-related complications and significantly shorter hospital stays. The investigators concluded that needle aspiration be used as a first-line, definitive treatment in management of a spontaneous pneumothorax. As emergency providers examine improved and equally effective approaches to care that are associated with less costs and potential complications, needle aspiration offers a beneficial approach and should be shared with patients when discussing treatment options to ensure shared decision making.

Outpatient management of primary spontaneous pneumothorax

The outpatient management of primary spontaneous pneumothorax (PSP) is still debated. The risk of a tension pneumothorax is used to justify active treatment like chest-tube drainage, although outpatient management can reduce both the time in hospital and the cost of treatment. It is also likely to be the patient's choice. This report is a reappraisal of the situations for which outpatient management, by monitoring alone, or using minimally invasive techniques, can be considered.

Needle aspiration for treating iatrogenic pneumothorax after cardiac electronic device implantation: a pilot study

Purpose

Pneumothorax (PTX) following cardiac implantable electronic device procedures is traditionally treated with chest tube drainage (CTD). We hypothesized that, in a subset of patients, the less invasive needle aspiration (NA) may also be effective. We compared the strategy of primary NA with that of primary CTD in a single-center observational study.

Methods

Of the 970 procedures with subclavian venous access between January 2016 and June 2018, 23 patients had PTX requiring intervention. Beginning with March 2017, the traditional primary CTD (9 cases) has been replaced by the “NA first” strategy (14 patients). Outcome measures were procedural success rate and duration of hospitalization evaluated both as time to event (log-rank test) and as a discrete variable (Wilcoxon-Mann-Whitney test).

Results

Needle aspiration was successful in 8/14 (57.1%) of the cases (95% CI 28.9–82.3%), whereas PTX resolved in all patients after CTD was 9/9 (100%, 95% CI 66.4–100.0%, p = 0.0481). Regarding length of hospital stay, intention to treat time to event analysis showed no difference between the two approaches (p = 0.73). Also, the median difference was not statistically significant (− 2.0 days, p = 0.17). In contrast, per protocol evaluation revealed reduced risk of prolonged hospitalization for NA patients (p = 0.0025) with a median difference of − 4.0 days (p = 0.0012). Failure of NA did not result in a meaningful delay in discharge timing as median difference was 1.5 days (p = 0.28).

Conclusions

Our data suggest that in a number of patients iatrogenic PTX may be successfully treated with NA resulting in shorter hospitalization without the risk of meaningful discharge delay in unsuccessful cases.

Techniques d’exsufflation d’un pneumothorax

Les pneumothorax rencontrés aux urgences peuvent être d’origine spontanée ou traumatique. L’exsufflation est une méthode thérapeutique simple du pneumothorax spontané primitif. Cette technique consiste à réaliser une aspiration par l’intermédiaire d’un cathéter, sans que le matériel soit laissé en place. Elle permet une prise en charge ambulatoire du patient et répond à des enjeux de qualité des soins (efficacité, simplicité, sécurité) et d’économie de la santé (diminution de la durée et du taux d’hospitalisation). L’exsufflation peut être réalisée via différents dispositifs tout simples d’utilisation, par voie antérieure ou axillaire. L’exsufflation à l’aiguille avec des cathéters de perfusion intraveineux est peu recommandée devant le risque d’échec lié à une longueur de cathéter inadaptée à la morphologie du patient. Les usages de drains de faible calibre avec la méthode de Seldinger ou de kits dédiés de thoracentèse sont à privilégier. Les complications sont moindres comparées à la pose d’un drain thoracique. Il s’agit le plus souvent d’obstruction ou de déplacement du cathéter. L’exsufflation est également un geste de sauvetage à réaliser en urgence en cas de pneumothorax suffocant. La bonne maîtrise de l’une de ces techniques est donc indispensable dans le cadre de la formation et de la pratique en médecine d’urgence.

Effect of Needle Aspiration of Pneumothorax on Subsequent Chest Drain Insertion in Newborns: A Randomized Clinical Trial

IMPORTANCE

Treatment options for a symptomatic pneumothorax in newborns include needle aspiration (NA) and chest drain (CD) insertion. There is little consensus as to the preferred treatment, reflecting a lack of evidence from clinical trials.

OBJECTIVE

To investigate whether treating pneumothoraces diagnosed on chest radiography (CR) in newborns receiving respiratory support with NA results in fewer infants having CDs inserted within 6 hours of diagnosis.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted from October 7, 2013, to December 21, 2016. The setting was 5 tertiary European neonatal intensive care units. Infants receiving respiratory support (endotracheal ventilation, continuous positive airway pressure, or supplemental oxygen >40%) who had a pneumothorax on CR that clinicians deemed needed treatment were eligible for inclusion.

INTERVENTIONS

Infants were randomly assigned (1:1) to drainage using NA or CD insertion, stratified by center and gestation at birth (<32 vs ≥32 weeks). Caregivers were not masked to group assignment. For NA, a needle was inserted between the ribs to aspirate air and was removed once air was no longer aspirated. A CD was inserted if clinicians deemed that the response was inadequate. For CD insertion, a drain was inserted between the ribs and was left in situ.

MAIN OUTCOMES AND MEASURES

The primary outcome was whether a CD was inserted on the side of the pneumothorax within 6 hours of diagnosis.

RESULTS

A total of 76 infants were randomly assigned, and 6 (4 assigned to NA and 2 to CD) were excluded because they met exclusion criteria at enrollment. Of the 70 remaining infants, 33 (16 male [48%]) were assigned to NA and 37 (22 male [59%]) to CD insertion. Their median (interquartile range [IQR]) gestational age was 31 (27-38) vs 31 (27-35) weeks, and their median (IQR) birth weight was 1385 (1110-3365) vs 1690 (1060-2025) g, respectively. Fewer infants assigned to NA had a CD inserted within 6 hours (55% [18 of 33] vs 100% [37 of 37]; relative risk, 0.55; 95% CI, 0.40-0.75) and during hospitalization (70% [23 of 33] vs 100% [37 of 37]; relative risk, 0.70, 95% CI, 0.56-0.87).

CONCLUSIONS AND RELEVANCE

Needle aspiration reduced the rate of CD insertion in symptomatic newborns with pneumothorax on CR. It should be used as the initial method of draining radiologically confirmed pneumothorax in symptomatic infants.

TRIAL REGISTRATION

isrctn.org Identifier: ISRCTN65161530.

Chest tube drainage versus needle aspiration for primary spontaneous pneumothorax: which is better?

Background

Needle aspiration and chest tube drainages are two main treatments for primary spontaneous pneumothorax (PSP). However, the application of needle aspiration or chest tube drainages has not reached a consensus. The aim of this study is to compare the needle aspiration with chest tube drainages in patients suffering with PSP and therefore help offer suggestions for clinical practice.

Methods

We searched literatures from PubMed, OVID and Web of Science from their inception to June 30, 2017. Continuous and dichotomous outcomes were expressed by weight mean difference (WMD) and risk ratio (RR) respectively, and each with 95% confidence intervals (CIs). We used the fixed effect or random effect model to perform quantitative synthesis.

Results

A total of 6 RCTs recruiting 458 participants were included in our analysis. On the basis of the six studies, our results indicated that compared with chest tube drainage applying needle aspiration shortened the hospital stay (WMD: ‒1.67 days; 95% CI: ‒2.25 to 1.08; P<0.001) and decreased hospitalization rate (RR: 0.40; 95% CI: 0.22-0.75; P=0.004). However, there was no difference regarding immediate success rate (RR: 1.01; 95% CI: 0.70-1.46; P=0.96) and one-year recurrence rate (RR: 0.89; 95% CI: 0.58-1.38; P=0.61).

Conclusions

In the light of this present research, it is necessary to apply needle aspiration into treating PSP to reduce hospitalization rate and shorten hospital stay. However, the two treatments have no significant difference with respect to immediate success rate, one-year recurrence rate, one-week success rate, three-month recurrence rate or complication rate.

Simple aspiration versus intercostal tube drainage for primary spontaneous pneumothorax in adults

BACKGROUND

For management of pneumothorax that occurs without underlying lung disease, also referred to as primary spontaneous pneumothorax, simple aspiration is technically easier to perform than intercostal tube drainage. In this systematic review, we seek to compare the clinical efficacy and safety of simple aspiration versus intercostal tube drainage for management of primary spontaneous pneumothorax. This review was first published in 2007 and was updated in 2017.

OBJECTIVES

To compare the clinical efficacy and safety of simple aspiration versus intercostal tube drainage for management of primary spontaneous pneumothorax.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 1) in the Cochrane Library; MEDLINE (1966 to January 2017); and Embase (1980 to January 2017). We searched the World Health Organization (WHO) International Clinical Trials Registry for ongoing trials (January 2017). We checked the reference lists of included trials and contacted trial authors. We imposed no language restrictions.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) of adults 18 years of age and older with primary spontaneous pneumothorax that compared simple aspiration versus intercostal tube drainage.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, assessed trial quality, and extracted data. We combined studies using the random-effects model.

MAIN RESULTS

Of 2332 publications obtained through the search strategy, seven studies met the inclusion criteria; one study was ongoing and six studies of 435 participants were eligible for inclusion in the updated review. Data show a significant difference in immediate success rates of procedures favouring tube drainage over simple aspiration for management of primary spontaneous pneumothorax (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.69 to 0.89; 435 participants, 6 studies; moderate-quality evidence). Duration of hospitalization however was significantly less for patients treated by simple aspiration (mean difference (MD) -1.66, 95% CI -2.28 to -1.04; 387 participants, 5 studies; moderate-quality evidence). A narrative synthesis of evidence revealed that simple aspiration led to fewer adverse events (245 participants, 3 studies; low-quality evidence), but data suggest no differences between groups in terms of one-year success rate (RR 1.07, 95% CI 0.96 to 1.18; 318 participants, 4 studies; moderate-quality evidence), hospitalization rate (RR 0.60, 95% CI 0.25 to 1.47; 245 participants, 3 studies; very low-quality evidence), and patient satisfaction (median between-group difference of 0.5 on a scale from 1 to 10; 48 participants, 1 study; low-quality evidence). No studies provided data on cost-effectiveness.

AUTHORS' CONCLUSIONS

Available trials showed low to moderate-quality evidence that intercostal tube drainage produced higher rates of immediate success, while simple aspiration resulted in a shorter duration of hospitalization. Although adverse events were reported more commonly for patients treated with tube drainage, the low quality of the evidence warrants caution in interpreting these findings. Similarly, although this review observed no differences between groups when early failure rate, one-year success rate, or hospital admission rate was evaluated, this too needs to be put into the perspective of the quality of evidence, specifically, for evidence of very low and low quality for hospitalization rate and patient satisfaction, respectively. Future adequately powered research is needed to strengthen the evidence presented in this review.

Thoracic Trauma: Injuries, Evaluation, and Treatment

Thoracic injury is common in high-energy and low-energy trauma, and is associated with significant morbidity and mortality. Evaluation requires a systematic approach prioritizing airway, respiration, and circulation. Chest injuries have the potential to progress rapidly and require prompt procedural intervention. For the diagnosis of nonemergent injuries, a careful secondary survey is essential. Although medicine and trauma management have evolved throughout the decades, the basics of thoracic trauma care have remained the same.