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Owen GS, Harmon KA, Sullivan GA, Petit HJ, Westrick J, Cameron JR, Gulack BC, Shah AN. Methods of measurement for pneumothorax in pediatric patients: a systematic review. Pediatr Surg Int 2024; 40:77. [PMID: 38472473 DOI: 10.1007/s00383-024-05640-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/28/2024] [Indexed: 03/14/2024]
Abstract
Accurate measurement of pneumothorax (PTX) size is necessary to guide clinical decision making; however, there is no consensus as to which method should be used in pediatric patients. This systematic review seeks to identify and evaluate the methods used to measure PTX size with CXR in pediatric patients. A systematic review of the literature through 2021 following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was conducted using the following databases: Ovid/MEDLINE, Scopus, Cochrane Database of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar. Original research articles that included pediatric patients (< 18 years old) and outlined the PTX measurement method were included. 45 studies were identified and grouped by method (Kircher and Swartzel, Rhea, Light, Collins, Other) and societal guideline used. The most used method was Collins (n = 16; 35.6%). Only four (8.9%) studies compared validated methods. All found the Collins method to be accurate. Seven (15.6%) studies used a standard classification guideline and 3 (6.7%) compared guidelines and found significant disagreement between them. Pediatric-specific measurement guidelines for PTX are needed to establish consistency and uniformity in both research and clinical practice. Until there is a better method, the Collins method is preferred.
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Affiliation(s)
- Grant S Owen
- Rush Medical College, Rush University Medical Center, Chicago, IL, USA
| | - Kelly A Harmon
- Rush Medical College, Rush University Medical Center, Chicago, IL, USA
| | - Gwyneth A Sullivan
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, 1653 W. Congress Parkway, Suite 794, Chicago, IL, 60612, USA
| | - Hayley J Petit
- Rush Medical College, Rush University Medical Center, Chicago, IL, USA
| | - Jennifer Westrick
- Library of Rush Medical Center, Rush University Medical Center, Chicago, IL, USA
| | - James R Cameron
- Department of Diagnostic Radiology and Nuclear Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Brian C Gulack
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, 1653 W. Congress Parkway, Suite 794, Chicago, IL, 60612, USA
| | - Ami N Shah
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, 1653 W. Congress Parkway, Suite 794, Chicago, IL, 60612, USA.
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Improving care through standardized treatment of spontaneous pneumothorax. J Pediatr Surg 2021; 56:55-60. [PMID: 33139032 DOI: 10.1016/j.jpedsurg.2020.09.048] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 09/22/2020] [Indexed: 11/23/2022]
Abstract
PURPOSE The objective of this quality improvement (QI) initiative was to implement a standardized clinical treatment protocol for patients presenting with primary spontaneous pneumothorax (PSP) in order to decrease hospital length of stay (LOS), diagnostic radiation exposure, and related cost. METHODS Baseline data from patients admitted with PSP from January 1, 2016 to July 31, 2018 were compared to data from patients managed using a newly developed evidence-based treatment pathway from August 1, 2018 to December 31, 2019. Standard QI methodology was used to track results. RESULTS Fifty-six episodes of PSP were observed during the baseline period and 40 episodes of PSP following initiation of the PSP protocol. The average LOS decreased from 4.5 days to 2.9 days. Patients underwent an average of 8.8 X-rays per admission preintervention versus 5.9 postintervention. The rate of CT scans decreased from 45% to 15% (p = 0.002). There was no significant difference in the rates of 30-day recurrence between the preintervention (13%) and postintervention (10%) groups (p = 0.7). Average admission costs per patient decreased by $1322 after adoption of the pathway. CONCLUSIONS Adoption of a standardized treatment protocol for PSP led to a reduction in LOS, diagnostic imaging utilization, and cost without increasing clinical recurrence. TYPE OF STUDY Quality improvement. LEVEL OF EVIDENCE Level III.
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Tang S, Lau H, Chan J. The Effectiveness of Catheter Aspiration in the Treatment of Spontaneous Pneumothorax. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490790200900103] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Catheter aspiration is a simple and minimal invasive method to treat spontaneous pneumothorax. It was recommended by British Thoracic Society in 1993 as the treatment for spontaneous pneumothorax. This study was designed to evaluate the effectiveness of catheter aspiration in the treatment of spontaneous pneumothorax. The protocol involved catheter placement by using Seldinger technique and serial chest X-rays were used to document the degree of lung re-expansion. We report a case series study in which eight patients were recruited into the study. All patients' pneumothorax re-expanded well after the initial attempt of aspiration. However, during the observation period, 5 patients had recurrence of pneumothorax requiring further aspiration. Despite that, these 5 patients finally required chest drain insertion. The remaining 3 patients were discharged after aspiration and were followed up on the following day. Two patients had recurrent pneumothorax and required further intervention. One patient had uneventful recovery. Conclusion catheter aspiration was effective in relieving spontaneous pneumothorax but with a high recurrence rate.
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Affiliation(s)
- Syh Tang
- Alice Ho Miu Ling Nethersole Hospital, Accident and Emergency Department, 11 Chuen On Road, Tai Po, N.T., Hong Kong
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Law PK, Lui CT, Lee MM, Tsui KL, Tang YH. Shorter Symptoms Onset to Emergency Department Presentation Time Predicts Failure of Needle Aspiration in Primary Spontaneous Pneumothorax. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791402100103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective To evaluate factors in predicting the failure of needle aspiration in primary spontaneous pneumothorax, in particular the interval between symptom onset and emergency department presentation. Methods This is a retrospective cohort study carried out from January 2010 to October 2012 in two public hospitals in Hong Kong. All consecutive adult patients aged 18 or more who attended the emergency departments in the study period with the diagnosis of primary spontaneous pneumothorax, where needle aspiration was performed as the primary treatment were recruited. Age, smoking status, previous pneumothorax, symptom interval, size of pneumothorax and aspirated gas volume were included in the analysis. The outcome was successful or failed needle aspiration. Logistic regression was used to identify independent predictors of failed needle aspiration. Results A total of 196 patients were included. Overall, 105 patients (53.6%) were treated successfully with no recurrence upon discharge. Among those failure patient, 30 patients (15.3%) failed as evidence by the chest X-ray taken immediately after the procedure while 61 patients (31.1%) failed upon subsequent chest X-ray. Multivariate logistic regression showed factors independently associated with failure of needle aspiration included size of pneumothorax (apex to cupola distance) (odds ratio [OR]=1.022, 95% confidence interval [CI]=1.009-1.039, p=0.001) and symptoms onset to emergency department presentation time (OR=0.987, 95% CI=0.976-0.999, p=0.028). Conclusions Large pneumothorax and shorter symptoms onset to emergency department presentation time were associated with higher failure rate of needle aspiration for primary spontaneous pneumothorax. (Hong Kong j.emerg. med. 2014;21:16-22)
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Siu AYC, Chung CH. A Case Series of Using Aspiration Catheter for the Management of Spontaneous Pneumothorax. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490790301000405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction Catheter aspiration is a relatively new treatment for spontaneous pneumothorax in emergency departments in Hong Kong. It causes less pain and shortens hospitalisation. However, there is limited local experience especially in regard to the target group that can be benefited. We reported on the initial experience of catheter aspiration in the management of spontaneous pneumothorax in our emergency department. Method Patients (age >=16 years) presenting with spontaneous pneumothorax were recruited. Patients with history of asthma or chronic obstructive airway disease were excluded. History of smoking, previous pneumothorax and pleurodesis were recorded. The aspiration catheter was inserted by the Seldinger technique. The extent of pneumothorax was assessed from the chest X-ray and initial aspirated volume. Successful patients were observed in the department and discharged if chest X-rays were reassuring after 12 hours. Factors associated with the outcome of patients were analysed. Result Seventeen patients were recruited from October 1999 to September 2000. Their age ranged from 16 to 40 years (mean 22.6). The overwhelming majority (16) was male. Twelve cases (70.6%) occurred on the left side. Five patients had previous pneumothorax and one had previous pleurodesis. Fifteen succeeded in immediate re-expansion, but seven re-collapsed during observation. The overall success rate was 47.1%. Initial aspiration volume >2,000 ml was associated with early failure (p=0.01). Conclusion Our initial experience did not support catheter aspiration to completely replace chest drain in the initial management of spontaneous pneumothorax. The procedure is likely to fail if the initial aspirated volume is greater than 2,000 ml. Further study is needed to identify the subgroup that may be benefited.
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Affiliation(s)
- AYC Siu
- North District Hospital, Accident and Emergency Department, 9 Po Kin Road, Sheung Shui, N.T., Hong Kong
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Tsai TM, Lin MW, Li YJ, Chang CH, Liao HC, Liu CY, Hsu HH, Chen JS. The Size of Spontaneous Pneumothorax is a Predictor of Unsuccessful Catheter Drainage. Sci Rep 2017; 7:181. [PMID: 28298628 PMCID: PMC5428034 DOI: 10.1038/s41598-017-00284-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 02/20/2017] [Indexed: 11/09/2022] Open
Abstract
Small-bore thoracic catheter drainage is recommended for a first large or symptomatic episode of primary spontaneous pneumothorax (PSP). However, one-third of these patients require a second procedure because of treatment failure. We investigated the factors associated with unsuccessful pigtail catheter drainage in the management of PSP. In this retrospective study, using a prospectively collected database, we enrolled 253 consecutive patients with PSP who underwent pigtail catheter drainage as initial treatment, from December 2006 to June 2011. The chest radiograph was reviewed in each case and pneumothorax size was estimated according to Light’s index. Other demographic factors and laboratory data were collected via chart review. Pigtail catheter drainage was successful in 71.9% (182/253) of cases. Treatment failure rates were 42.9%, 25.9%, and 15.5% in patients with pneumothorax sizes of >62.6%, 38–62.6%, and <38%, respectively (tertiles). An alternative cut-off point of 92.5% lung collapse was defined using a classification and regression tree method. According to the multivariate analysis, a large-size pneumothorax (p = 0.009) was the only significant predictor of initial pigtail catheter drainage treatment failure in patients with PSP. Early surgical treatment could be considered for those patients with a large-sized pneumothorax.
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Affiliation(s)
- Tung-Ming Tsai
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, 10002, Taiwan
| | - Mong-Wei Lin
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, 10002, Taiwan
| | - Yao-Jen Li
- Graduate Institute of Epidemiology, College of Public Health, National Taiwan University, Taipei, 10055, Taiwan.,Genomic Research Center, Academia Sinica, Taipei, 11529, Taiwan
| | - Chin-Hao Chang
- Department of Medical Research, National Taiwan University Hospital, Taipei, 10002, Taiwan
| | - Hsien-Chi Liao
- Department of Traumatology, National Taiwan University Hospital, Taipei, 10002, Taiwan
| | - Chao-Yu Liu
- Division of Thoracic Surgery, Department of Surgery, Far Eastern Memorial Hospital, New Taipei City, 22060, Taiwan
| | - Hsao-Hsun Hsu
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, 10002, Taiwan.
| | - Jin-Shing Chen
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, 10002, Taiwan. .,Department of Traumatology, National Taiwan University Hospital, Taipei, 10002, Taiwan.
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Moubachir H, Zaghba N, Benjelloun H, Bakhatar A, Yassine N. [Treatment of the first episode of spontaneous pneumothorax]. Rev Mal Respir 2016; 33:789-793. [PMID: 27017062 DOI: 10.1016/j.rmr.2015.11.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Accepted: 11/13/2015] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The management of a first episode of spontaneous pneumothorax is controversial and the best technique to be used as an initial intervention, aspiration or intercostal drainage, is still debated. PATIENTS AND METHODS We present a retrospective case series during two and a half consecutive years describing the immediate management of spontaneous pneumothoraces, comparing aspiration versus thoracic drainage. RESULTS One hundred and thirty-three clinical files from patients with spontaneous pneumothoraces were analyzed (17 primary and 116 secondary). The pneumothoraces were of varying size and different etiologies. Patients were initially treated with simple aspiration in 68 cases, with an immediate success rate of 37.5%, intercostal drainage in 49 cases, and by rest alone in 16 cases. CONCLUSION In case of secondary pneumothorax, aspiration appeared to offer advantages as an initial strategy over intercostal drainage in terms of hospital stay (11 versus 22 days), and with significant effectiveness (37.5%).
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Affiliation(s)
- H Moubachir
- Service des maladies respiratoires, CHU Ibn Rochd, Casablanca, Maroc.
| | - N Zaghba
- Service des maladies respiratoires, CHU Ibn Rochd, Casablanca, Maroc
| | - H Benjelloun
- Service des maladies respiratoires, CHU Ibn Rochd, Casablanca, Maroc
| | - A Bakhatar
- Service des maladies respiratoires, CHU Ibn Rochd, Casablanca, Maroc
| | - N Yassine
- Service des maladies respiratoires, CHU Ibn Rochd, Casablanca, Maroc
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Robinson PD, Blackburn C, Babl FE, Gamage L, Schutz J, Nogajski R, Dalziel S, Donald CB, Druda D, Krieser D, Neutze J, Acworth J, Lee M, Ngo PK. Management of paediatric spontaneous pneumothorax: a multicentre retrospective case series. Arch Dis Child 2015; 100:918-23. [PMID: 25670402 DOI: 10.1136/archdischild-2014-306696] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 01/19/2015] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Paediatric guidelines are lacking for management of spontaneous pneumothorax. Adult patient-focused guidelines (British Thoracic Society 2003 and 2010) introduced aspiration as first-line intervention for primary spontaneous pneumothorax (PSP) and small secondary spontaneous pneumothoraces (SSP). Paediatric practice is unclear, and evidence for aspiration success rates is urgently required to develop paediatric-specific recommendations. METHODS Retrospective analysis of PSP and SSP management at nine paediatric emergency departments across Australia and New Zealand (2003-2010) to compare PSP and SSP management. RESULTS 219 episodes of spontaneous pneumothorax occurred in 162 children (median age 15 years, 71% male); 155 PSP episodes in 120 children and 64 SSP episodes in 42 children. Intervention in PSP vs SSP episodes occurred in 55% (95% CI 47% to 62%) vs 70% (60% to 79%), p<0.05. An intercostal chest catheter (ICC) was used in 104/219 (47%) episodes. Aspiration was used in more PSP than in SSP episodes with interventions (27% (18% to 37%) vs 9% (3% to 21%), p<0.05). Aspiration success was 52% (33% to 70%) overall and not significantly different between PSP and SSP. Aspiration success was greater in small vs large pneumothoraces (80% (48% to 95%) vs 33% (14% to 61%), p=0.01). Small-bore ICCs were used in 40% of ICCs and usage increased during the study. CONCLUSIONS In this descriptive study of pneumothorax management, PSP and SSP management did not differ and ICC insertion was the continuing preferred intervention. Overall success of aspiration was lower than reported results for adults, although success was greater for small than for large pneumothoraces. Paediatric prospective studies are urgently required to determine optimal paediatric interventional management strategies.
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Affiliation(s)
- Paul D Robinson
- Department of Respiratory Medicine, Children's Hospital at Westmead, Sydney, New South Wales, Australia Discipline of Paediatrics and Child Health, University of Sydney, Sydney, Australia
| | - Carol Blackburn
- Royal Children's Hospital, Murdoch Children's Research Institute and University of Melbourne, Melbourne, Australia
| | - Franz E Babl
- Royal Children's Hospital, Murdoch Children's Research Institute and University of Melbourne, Melbourne, Australia
| | - Lalith Gamage
- Emergency Department, Children, Youth and Women's Health Service, Adelaide, Australia
| | - Jacquie Schutz
- Emergency Department, Children, Youth and Women's Health Service, Adelaide, Australia
| | - Rebecca Nogajski
- Emergency Department, Sydney Children's Hospital, Sydney, Australia
| | - Stuart Dalziel
- Starship Hospital, Auckland, New Zealand Liggins Institute, University of Auckland, New Zealand
| | | | - Dino Druda
- Emergency Medicine Department, Sunshine Hospital, St Albans, Victoria, Australia
| | - David Krieser
- Emergency Medicine Department, Sunshine Hospital, St Albans, Victoria, Australia
| | - Jocelyn Neutze
- Emergency Medicine Department, Kidzfirst Middlemore Hospital, Otahuhu, New Zealand
| | - Jason Acworth
- Emergency Medicine Department, Royal Children's Hospital, Brisbane, Australia
| | - Mark Lee
- Emergency Medicine Department, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Peter K Ngo
- Department of Respiratory Medicine, Children's Hospital at Westmead, Sydney, New South Wales, Australia
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Tsuchiya T, Sano A. Outpatient Treatment of Pneumothorax with a Thoracic Vent: Economic Benefit. Respiration 2015; 90:33-9. [PMID: 25997413 DOI: 10.1159/000381958] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 03/27/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Since rising medical costs currently represent a growing problem worldwide, finding cost-effective treatment options is important. In our hospital, outpatient treatment of pneumothorax using a thoracic vent began in December 2012. OBJECTIVES We aimed to test our hypothesis that outpatient treatment of pneumothorax with a thoracic vent can reduce medical expenses. METHODS Patients were classified into four groups based on treatment: thoracic vent with or without surgery or conventional intercostal chest tube drainage with or without surgery. We compared mean medical expenses, duration of hospitalization and number of physician visits among these four groups. RESULTS During a 2-year period, 65 patients were treated with a thoracic vent (36 patients) or conventional intercostal chest tube drainage (29 patients). Patients treated with a thoracic vent who underwent surgery had a shorter mean duration of hospitalization (5.0 ± 1.3 vs. 10.3 ± 3.4 days; p < 0.0001) and lower overall cost, at JPY 971,830.00 ± 81,291.80 (USD 10,400.40 ± 1,464.90) versus JPY 1,179,791.10 ± 198,383.10 (USD 13,888.90 ± 1,965.30; p < 0.0001) compared with conventional intercostal chest tube drainage. Nonsurgical patients treated with a thoracic vent had lower overall costs, at JPY 79,960.00 ± 25,643.60 (USD 890.10 ± 352.30) versus JPY 268,588.80 ± 94,636.50 (USD 2,932.80 ± 903.50; p < 0.0001) compared with conventional intercostal chest tube drainage. No serious complications were observed. CONCLUSIONS Outpatient thoracic vent treatment can significantly reduce medical expenses and thereby have a major economic impact.
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Affiliation(s)
- Takehiro Tsuchiya
- Department of Thoracic Surgery, Chigasaki Municipal Hospital, Chigasaki, Japan
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Desmettre T, Meurice JC, Mauny F, Woronoff MC, Tiffet O, Schmidt J, Ferretti G, Dalphin JC. [Comparison of simple aspiration versus standard drainage in the treatment of large primary spontaneous pneumothorax]. Rev Mal Respir 2011; 28:336-43. [PMID: 21482337 DOI: 10.1016/j.rmr.2010.10.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Accepted: 10/26/2010] [Indexed: 11/28/2022]
Abstract
BACKGROUND Chest tube drainage is the standard treatment of a large spontaneous pneumothorax. Aspiration is an alternative technique that is simple and rapid to learn, and the success rate seems identical to chest tube drainage. Its widespread use justifies studies to define its place in the management strategy of spontaneous pneumothorax. METHODS We propose a multicentre, prospective, randomized, open trial with two parallel groups. The main objective is to compare the therapeutic efficacy of a simple aspiration with chest tube drainage for a first large spontaneous pneumothorax. The hypothesis is that aspiration is not inferior to a chest drain in its immediate effect. The secondary objectives are to compare the therapeutic efficacy at 24h and at one-week, the relapse rate at one year, and the tolerance and complications. A comparison of both the medical and economic aspects will be made. With an α-risk of 0.05 and a β-risk of 0.10, a proportion of failures of 30% expected in both groups and a target of non-inferiority of δ=0.15, the number of subjects to be included is 200 per group, totalling 400 in all. EXPECTED RESULTS In the case of equivalence, this study should help to better define the place of aspiration compared to chest tube drainage in the management of spontaneous pneumothorax.
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Affiliation(s)
- T Desmettre
- Pôle urgences/réanimation médicale/samu, service d'accueil des urgences/samu 25, hôpital Jean-Minjoz, CHU de Besançon, boulevard Fleming, Besançon cedex, France.
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Robinson PD, Cooper P, Ranganathan SC. Evidence-based management of paediatric primary spontaneous pneumothorax. Paediatr Respir Rev 2009; 10:110-7; quiz 117. [PMID: 19651381 DOI: 10.1016/j.prrv.2008.12.003] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The exact incidence of paediatric primary spontaneous pneumothorax (PSP) is unclear, although PSP incidence in the general population is between 6 and 18 per 100,000. PSP has been reported throughout the paediatric age range. A potential genetic predisposition for familial cases has been recently identified. Whilst there is universal consensus on the management of tension pneumothorax, lack of agreement and consistency exists across a wide range of management issues for other aspects of PSP management. Paediatric PSP may have a higher recurrence rate than adult PSP, and the presence of apical lung cysts or bullae is not predictive of recurrence. The decision for surgical intervention should be based on documented recurrence. There is a lack of paediatric evidence to guide management decisions, and extrapolation of predominantly adult data to younger age groups should not be encouraged. Given the relatively low apparent incidence, a multicentre approach to future research is required in order to generate the evidence required for informed management of PSP in children.
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Affiliation(s)
- Paul D Robinson
- Department of Respiratory Medicine, The Children's Hospital at Westmead, NSW, 2145 Australia.
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13
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Chen JS, Hsu HH, Tsai KT, Yuan A, Chen WJ, Lee YC. Salvage for unsuccessful aspiration of primary pneumothorax: thoracoscopic surgery or chest tube drainage? Ann Thorac Surg 2008; 85:1908-13. [PMID: 18498793 DOI: 10.1016/j.athoracsur.2008.02.038] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2007] [Revised: 02/12/2008] [Accepted: 02/13/2008] [Indexed: 12/15/2022]
Abstract
BACKGROUND Simple aspiration is recommended as first-line treatment for all primary spontaneous pneumothoraces requiring intervention. However, the optimal salvage treatment remains unclear when simple aspiration is unsuccessful for controlling symptoms. In this study, the safety, efficacy, and estimated costs of video-assisted thoracoscopic surgery (VATS) and chest tube drainage (CTD) were compared. METHODS Between 2002 and 2007, 164 patients with a first episode of spontaneous pneumothorax were managed by simple aspiration. Among them, 52 patients underwent subsequent VATS (30 patients) or CTD (22 patients) due to unsuccessful aspiration. The demographic data and treatment outcomes of the two groups were collected through retrospective chart review. RESULTS Postoperative analgesics use did not differ between groups. Complications developed in 2 of the VATS group (6.7%) and 6 of the CTD group (27.3%), with mean hospital stays of 4.8 and 6.1 days, respectively (p = 0.034). Patients in the VATS group had lower rates of overall failure, although the rates of immediate failure were not significantly different. After a mean follow-up of 16 months, recurrent ipsilateral pneumothorax was noted in 1 VATS patient and 5 CTD individuals (p = 0.038). The estimated total costs per patient were $1,273 in the VATS group and $865 in the CTD group. CONCLUSIONS Although associated with higher costs, VATS rather than CTD is the preferred salvage treatment for unsuccessful aspiration of the first episode of primary spontaneous pneumothorax, because of shorter hospital stay and lower rates of overall failure and recurrence.
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Affiliation(s)
- Jin-Shing Chen
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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Chan SSW. The Role of Simple Aspiration in the Management of Primary Spontaneous Pneumothorax. J Emerg Med 2008; 34:131-8. [DOI: 10.1016/j.jemermed.2007.05.040] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2006] [Revised: 12/01/2006] [Accepted: 02/11/2007] [Indexed: 11/29/2022]
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Kelly AM. Review of management of primary spontaneous pneumothorax: is the best evidence clearer 15 years on? Emerg Med Australas 2007; 19:303-8. [PMID: 17655631 DOI: 10.1111/j.1742-6723.2007.00997.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In 1993 Emergency Medicine Australasia (then Emergency Medicine [Fremantle]) published a therapeutic review on the management of spontaneous pneumothorax. That review found a lack of high-quality evidence on which to base management decisions and a variety of therapeutic options without clear superiority one over another. Now, almost 15 years later, the present paper aims to revisit the evidence base to see if management choices are clearer.
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Affiliation(s)
- Anne-Maree Kelly
- Joseph Epstein Centre for Emergency Medicine Research, Western Health, St Albans, Australia.
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Chan SSW, Lam PKW. Simple aspiration as initial treatment for primary spontaneous pneumothorax: Results of 91 consecutive cases. J Emerg Med 2005; 28:133-8. [PMID: 15707806 DOI: 10.1016/j.jemermed.2004.11.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2003] [Revised: 09/16/2004] [Accepted: 09/16/2004] [Indexed: 11/19/2022]
Abstract
Varying opinions exist regarding the choice of initial treatment for primary spontaneous pneumothorax (PSP). This study aims to determine the success rate of simple aspiration of PSP, identify factors associated with failure, and identify associated complications. A retrospective analysis was performed on 91 consecutive patients receiving simple aspiration for PSP at the Emergency Department of a university teaching hospital in Hong Kong, China. The overall success rate was 50.5%. Failed cases had significantly larger sizes of pneumothorax, and significantly larger volumes of air aspirated. Pneumothorax size > or =40% was significantly associated with failure. In a multivariate analysis, pneumothorax size > or =40%, compared to size 21-39%, independently predicted failure, with an odds ratio of 8.88 (95% CI, 2.49 to 31.63). Complications were rarely encountered. It is concluded that the success rate may be significantly improved by excluding patients with pneumothorax size 40% or larger from this modality of treatment.
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Affiliation(s)
- Stewart S W Chan
- Accident and Emergency Medicine Academic Unit, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
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Noppen M, Alexander P, Driesen P, Slabbynck H, Verstraeten A. 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; 165:1240-4. [PMID: 11991872 DOI: 10.1164/rccm.200111-078oc] [Citation(s) in RCA: 172] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Although there is no agreement on the optimal treatment of patients presenting with a first episode of primary spontaneous pneumothorax, the majority of physicians prefer chest tube drainage for air evacuation. Manual aspiration of air has been proposed by some, but lack of sound comparative data and safety data has limited its use. In this first randomized, prospective, multicenter pilot study, 60 patients with a first episode of primary spontaneous pneumothorax were randomly allocated to manual aspiration (n = 27) or chest tube drainage (n = 33). Immediate success was obtained in 16 out of 27 (59.3%) in the manual aspiration group, and in 21 out of 33 (63.6%) in the chest tube drainage group (p = 0.9). One-week success rates were 25 out of 27 (93%) in the intention-to-treat manual aspiration group and 28 out of 33 (85%) in the chest tube drainage group (p = 0.4). Fourteen of 27 manual aspiration patients (52%) were hospitalized, versus 100% of the chest tube drainage patients (p < 0.0001). Recurrence rates with at least 1-year follow-up were 7 out of 26 (26%) in the manual aspiration group, and 9 out of 33 (27.3%) in the chest tube drainage group (p = 0.9). There were no complications associated with manual aspiration. Although statistical power is insufficient to formally confirm therapeutic equality, this pilot study suggests that in first episodes of primary spontaneous pneumothorax, manual aspiration seems equally effective as chest tube drainage and is safe, well tolerated, and feasible as an outpatient procedure in the majority of patients.
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Affiliation(s)
- Marc Noppen
- Vlaamse Werkgroep voor Medische Thoracoscopie en Interventionele Pneumologie, Brussels, Belgium.
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Mendis D, El-Shanawany T, Mathur A, Redington AE. Management of spontaneous pneumothorax: are British Thoracic Society guidelines being followed? Postgrad Med J 2002; 78:80-4. [PMID: 11807188 PMCID: PMC1742255 DOI: 10.1136/pmj.78.916.80] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
In 1993, the British Thoracic Society (BTS) issued guidelines for the management of spontaneous pneumothorax. The aim of this study was to determine the level of adherence to and awareness of these guidelines at a London teaching hospital. A retrospective case note audit of 59 episodes of acute spontaneous pneumothorax was performed. In patients undergoing intervention, the initial procedure was simple aspiration in 32 (73%) and chest tube insertion in 12 (27%) cases, contrasting with the BTS recommendation that aspiration should be attempted first in all such patients. Simple aspiration was successful on 34% of occasions. Successful aspiration was associated with a significantly shorter hospital stay (median 3, range 1-11 days) than either failed aspiration (7, 3-66 days; p=0.003) or chest tube insertion without aspiration (9, 3-16 days; p=0.005). Other areas where practice differed from the BTS guidelines were clamping of chest tubes and use of a pursestring suture for wound closure. A follow up questionnaire survey suggested a lack of familiarity with the guidelines. These findings indicate that current management of spontaneous pneumothorax deviates from the BTS guidelines in a number of potentially important respects. Attention should be directed to improving awareness of and access to clinical guidelines.
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Affiliation(s)
- D Mendis
- Guy's, King's, and St Thomas' School of Medicine, Guy's Hospital, London, UK
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Abstract
OBJECTIVE The aim of the present study was to determine treatment practices for spontaneous pneumothorax (PTX) in Australia. METHODOLOGY A questionnaire regarding treatment of PTX was posted to all medically qualified members of the Thoracic Society of Australia and New Zealand resident in Australia. RESULTS Fifty-three per cent (n = 226) of questionnaires were returned. Twenty-one responses were judged to be informal and rejected from analysis. The results indicate a general agreement in the treatment of small and large PTX but a wide variation in PTX of intermediate size. CONCLUSION Opinion regarding the optimal treatment for PTX of intermediate size was found to vary considerably. There is a need for evidence-based development and publication of best practice guidelines for PTX.
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Affiliation(s)
- M Sutherland
- Department of Respiratory Medicine, St Vincent's Hospital, Fitzroy, Victoria, Australia
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Soulsby T. British Thoracic Society guidelines for the management of spontaneous pneumothorax: do we comply with them and do they work? J Accid Emerg Med 1998; 15:317-21. [PMID: 9785159 PMCID: PMC1343172 DOI: 10.1136/emj.15.5.317] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To determine how British Thoracic Society (BTS) guidelines for the management of spontaneous pneumothorax have been implemented over a four year period in a large district general hospital with a specialised respiratory unit. To assess the validity of the guidelines in the management of spontaneous pneumothorax. METHODS A retrospective case notes study over a four year period for all patients with spontaneous pneumothoraces attending the accident and emergency (A&E) department of a large district general hospital. RESULTS 115 episodes of spontaneous pneumothorax were identified. Overall 20.8% of episodes were treated correctly by BTS guidelines. Decisions made by A&E staff were significantly more likely to be correct than decisions made by on call medical teams (39.4% v 13.4%, p = 0.002). There was a non-significant trend towards better compliance with BTS guidelines over the four year period. The management decision was made by A&E staff only in 28.7% of episodes. Patients without chronic lung disease could be safely observed as outpatients. Forty three pneumothoraces were aspirated: 23 (58%) successfully; eight (18.6%) with little or no improvement; and 12 (27.9%) initially successfully but developing increased size of pneumothorax within a period of 72 hours. Three patients had repeat aspirations, two successfully. Age over 50, chronic lung disease, and more than 2.5 litres of air aspirated were significantly associated with failure of aspiration (p < 0.01). There was a 28.6% failure rate of aspiration for patients with moderate pneumothoraces without chronic lung disease. CONCLUSIONS Patients over the age of 50 should be treated the same as patients with chronic lung disease. A second aspiration should be attempted if the first aspiration is initially successful with subsequent recurrence of pneumothorax. Further research is required to clarify if patients with moderate pneumothoraces under the age of 50 and no chronic lung disease should be aspirated or observed.
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Affiliation(s)
- T Soulsby
- Accident and Emergency Department, Fazakerley Hospital, Liverpool
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Martin T, Fontana G, Olak J, Ferguson M. Use of pleural catheter for the management of simple pneumothorax. Chest 1996; 110:1169-72. [PMID: 8915215 DOI: 10.1378/chest.110.5.1169] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
STUDY OBJECTIVE We assessed the use of a pleural catheter (Thoracic Vent) to determine its effectiveness in treating simple pneumothorax (PTX) and in preventing recurrent PTX. DESIGN A retrospective review was conducted of 84 patients treated with a pleural catheter for iatrogenic (52) and spontaneous (11 primary, 21 secondary) PTX between 1989 and 1994. PATIENTS There were 45 men and 39 women with a mean age of 50.4 years (range, 18 to 85 years). RESULTS Mean time to lung reexpansion was 0.5 +/- 0.1 days. Forty-five (57%) patients manifested an air leak after catheter placement for 2.0 +/- 0.2 days. The duration of time to catheter removal was 3.3 +/- 0.2 days. Seventy-one (85%) patients had resolution of PTX with this therapy alone. Thirteen patients (15%) failed to resolve their PTXs and required subsequent tube thoracostomy alone (6) or surgical therapy (7). Four of 11 patients who required tube thoracostomy also failed to respond to this therapy. Treatment failure was more common among patients with spontaneous PTX than with iatrogenic PTX (34% vs 4%; p < 0.005). During a mean follow-up of 3.0 +/- 0.2 years, 6 (7%) patients suffered recurrent PTX an average of 23 days after initial therapy. CONCLUSION This pleural catheter is effective in the management of simple iatrogenic and spontaneous PTX.
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Affiliation(s)
- T Martin
- Department of Surgery, University of Chicago Hospitals, IL 60637, USA
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Abstract
Unilateral, idiopathic pneumothorax (IP) is relatively common and occurs predominantly in males in their teens and twenties, with 85% presenting before age forty. In contrast, bilateral IP occurs rarely, with only three cases reported from 1977-87. To our knowledge, only one case of bilateral IP has been reported in the pediatric population, an adolescent male with likely recurrent disease. We present a case of a 7-year-old child with bilateral IP and discuss the diagnosis, pathophysiology, and treatment of this entity.
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Affiliation(s)
- P S Dayan
- Emergency Medical Trauma Center, Children's National Medical Center, Washington, District of Columbia 20010, USA
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Abstract
In a retrospective, case-note based, audit of the initial management of spontaneous pneumothoraces in a large teaching hospital, 38 events were identified in 37 patients admitted over 12 months to the end of September 1991. The initial management was intercostal tube drainage in 21 (55%), decided upon by middle grade staff, with a cost in terms of the duration of hospitalisation (median 7 (range 2-18) days), chest radiography (6 (3-10) films) and potential for complications including infections (3 wound, 2 chest). Aspiration was performed in only three cases, the remainder were managed by observation. We suggest that undue reliance is placed upon intercostal tube drainage to treat spontaneous pneumothoraces with aspiration alone performed too infrequently. Moreover, other deficiencies in management including the practise of drain clamping and incomplete follow-up were identified.
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Affiliation(s)
- C D Selby
- Department of Medicine, University of Edinburgh, Royal Infirmary
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Schoenenberger RA, Haefeli WE, Weiss P, Ritz R. Evaluation of conventional chest tube therapy for iatrogenic pneumothorax. Chest 1993; 104:1770-2. [PMID: 8252961 DOI: 10.1378/chest.104.6.1770] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
STUDY OBJECTIVE To assess conventional, large chest tube therapy in iatrogenic pneumothorax and to determine the optimal moment when to use more invasive procedures. DESIGN Retrospective chart review. SETTING Medical intensive care unit of a university hospital. PATIENTS Forty-seven patients with needle-induced iatrogenic pneumothorax. Twenty-four patients had an underlying pleural or pulmonary disorder. INTERVENTIONS After insertion of a 20- to 24-French plastic chest tube connected to an underwater seal, suction was maintained until gas egress stopped or up to 10 days in patients with a persisting gas leak. RESULTS In 96 percent, a definite occlusion of the pneumothorax was achieved. In all patients without an underlying lung disorder, gas egress stopped definitely after 72 h. In the presence of an underlying lung disorder, 92 percent of the pneumothoraces were healed after 10 days of continuous suction therapy. At 72 h, only 71 percent of the latter group were healed (p < 0.05 vs patients without lung disease). No major complication of chest tube therapy occurred. CONCLUSION Conventional chest tube therapy is a safe and effective treatment for iatrogenic pneumothorax. In patients with an underlying lung disease, gas egress may last for up to 10 days. In these patients, the earlier use of a more invasive approach may be justified if the air leak persists.
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Affiliation(s)
- R A Schoenenberger
- Department of Internal Medicine, University Hospital, Basel, Switzerland
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Schidlow DV, Taussig LM, Knowles MR. Cystic Fibrosis Foundation consensus conference report on pulmonary complications of cystic fibrosis. Pediatr Pulmonol 1993; 15:187-98. [PMID: 8327283 DOI: 10.1002/ppul.1950150311] [Citation(s) in RCA: 75] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- D V Schidlow
- Department of Pediatrics, Temple University School of Medicine, Philadelphia, PA 19134-1095
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