Management of spontaneous pneumothorax: are British Thoracic Society guidelines being followed?

Aetiology, clinical profile and management outcome of pneumothorax patients: A prospective study from Central India

Background

Pneumothorax (PT) is defined as the presence of air in the pleural cavity. Primary spontaneous pneumothorax (PSP) arises in an otherwise healthy person without any underlying lung disease. PSP occurs in people aged 20 to 30 years, with a peak incidence in the early twenties. The recurrence rate in spontaneous PT patients is approximately 10%-20%. In the present study, 50 cases of spontaneous PT were undertaken with an aim to analyse aetiology, clinical profile and management outcome of PT patients.

Materials and Methods

The present study was conducted for a period of 12 months, among 50 patients presenting with unilateral PT. The therapeutic interventions were indicated when there was a loss of volume of lungs of 32% or more, and this loss of volume was calculated using Collins method. The association between the side of PT, smoking status and size of PT were found using the Chi-square test, and the association between variables were considered significant if the P value was <0.05.

Results

In the present study, the male patients were 92.0% and only 8.0% of patients were females. The further history-taking of patients had shown that the mode of onset of PT was sudden in 72.0% of patients. Although the success rate of Intracth procedure was lower in comparison with the intercoastal drainage (ICD) procedure, the complication rate of Intracath was lower when compared with extensive subcutaneous.

Conclusion

PSP is less common than secondary spontaneous PT. Smoking is an independent risk factor for PT, and it delays its resorbtion.

Thoracic Surgeons' Perspective on the Management of Primary Spontaneous Pneumothorax

OBJECTIVE

The study aimed to determine the current practice of thoracic surgeons in the management of primary spontaneous pneumothorax in Saudi Arabia and to compare the results with the British Thoracic Society guidelines.

MATERIAL AND METHODS

This is a questionnaire-based study. The questionnaire included 41 questions and was directed to those involved in the management of primary spontaneous pneumothorax in Saudi Arabia; namely thoracic, cardiac, and general surgeons. It was distributed electronically through email. Out of 47 registered surgeons at the time of the study, 47 responses were obtained with a 100% response rate.

RESULTS

Among the participants, 39 were thoracic surgeons. It was noted that all surgeons agreed on ordering an initial chest radiograph and most would order an additional view. Also, approaches varied regarding grading systems used. While 26% of the respondents use the British Thoracic Society grading system, 16% follow the American College of Chest Physicians system, and the rest chose other parameters. The majority of surgeons would choose a chest tube of a size not greater than 28 Fr for initial placement. As for video-assisted thoracoscopic surgery, we noted that 55% of the respondents opted for 3 ports, while 36% would place 2 ports.

CONCLUSION

Primary spontaneous pneumothorax is a common condition managed by thoracic surgeons. Various guidelines were established to guide practice. Our study showed some variability in practice which could result in serious medico-legal consequences and can affect the careers of thoracic surgeons. We hope that our results will shed light upon variabilities to influence proper directed management.

Update in management of paediatric primary spontaneous pneumothorax

Paediatric spontaneous pneumothorax (PSP) management continues to lack paediatric-specific guideline recommendations. There have been increasing reports of paediatric retrospective case studies supplemented by important well designed RCT (predominantly) adult studies. Taken together, these suggest that conservative management may have an increasing role to play in the management of PSP and that aspiration may have limited utility as a first line intervention. Our local experience, as part of a multicentre retrospective analysis and subsequent audit of management since, corroborates recent published data: it highlights an increasing trend towards conservative management in spontaneous pneumothorax with similar rates of recurrence, compared to intervention, and low use of aspiration with similarly low success rates. We have therefore updated our local practice guidelines and share these with readers. Specifically, we have removed aspiration in the management of primary spontaneous pneumothorax and reserved intervention for children who are clinically unstable or show evidence of increasing air leak irrespective of pneumothorax size. Whilst the success of this change in clinical practice will need to be reviewed in the next 5-10 years, the overall low incidence of the condition, demands a multicentre, and probably multinational, collaborative approach to allow the best chance of obtaining definitive evidence to guide clinical paediatric management.

Management of Pneumothorax

Pneumothorax is a common medical condition encountered in a wide variety of clinical presentations, ranging from asymptomatic to life threatening. When symptomatic, it is important to remove air from the pleural space and provide re-expansion of the lung. Additionally, patients who experience a spontaneous pneumothorax are at high risk for recurrence, so treatment goals also include recurrence prevention. Several recent studies have evaluated less invasive management strategies for pneumothorax, including conservative or outpatient management. Future studies may help to identify who is greatest at risk for recurrence and direct earlier definitive management strategies, including thoracoscopic surgery, to those patients.

Clamping of chest drain before removal in spontaneous pneumothorax

BACKGROUND

In spontaneous pneumothorax, clamping the chest drain before its removal may avoid reinsertion in case of early recurrence, but may be unsafe and may prolong hospital stay. The objective of this study was to examine the incidence of early recurrence in both clamped and unclamped pneumothorax episodes, and factors associated with it.

METHODS

Retrospective chart review of primary and secondary spontaneous pneumothorax episodes in which chest drain was inserted during the period April 2012 to March 2014.

RESULTS

Data of 122 episodes were analysed. There were 36 primary pneumothorax and 86 secondary pneumothorax episodes. Mean age was 59 years with 92% males. Clamping of the chest drain was done in 68 episodes (55.7%), and not done in 54. The clamping group was significantly younger, had more primary pneumothorax, and had shorter time from cessation of air leak to clamp/removal. Recurrence within 24 h were seen in 12 (17.6%) clamped episodes and 4 (7.4%) non-clamped episodes, although in only eight episodes were reinsertion of chest drain saved. Significantly more previous pneumothorax episodes were seen in the early recurrence group. We observed no new onset of tension pneumothorax or subcutaneous emphysema associated with clamping.

CONCLUSION

The practice of clamping the chest drain before removal in spontaneous pneumothorax appear safe. Clamping saved chest drain reinsertion in 11.8% of cases, and has the potential to save more if clamped for up to 24 h. However, clamping may result in more early recurrences. Prospective randomised studies are needed.

Randomized controlled trial on the comparison of chest tube drainage and needle aspiration in the treatment of primary spontaneous pneumothorax

Objectives

To evaluate the efficacy of the chest tube drainage (CTD) and the needle aspiration (NA) in the treatment of primary Spontaneous pneumothorax (SP).

Methods

In a randomized controlled trial, seventy patients suffering SP were divided equally into two subgroups, as follows: (A) CTD and (B) NA. The immediate and one-week rate of the treatments was the primary endpoints. Postoperative complications, length of hospital stay and incidence of pneumothorax recurrence during one-year follow up were also recorded.

Results

The immediate success of treatment was 68.5% and 54.2% of patients in CTD and NA groups, respectively that showed no significant difference between study groups (P: 0.16). The complete lung expansion after one week observed in 32 (91.4%) of NA group and 33 (94.2%) patients in CTD group (P: 0.5). Pneumothorax recurrence was detected in 13 patients (4 in NA and 9 in CTD group) (P: 0.11). Mean pain intensity was significantly lower in the NA group at the first hour after the procedure, the first postoperative day and the first week after the intervention (P< 0.001).

Conclusion

Needle aspiration (NA) can be applied as a first step treatment in patients with primary SP, considering its advantages.

Shorter Symptoms Onset to Emergency Department Presentation Time Predicts Failure of Needle Aspiration in Primary Spontaneous Pneumothorax

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)

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.

Randomised comparison of needle aspiration and chest tube drainage in spontaneous pneumothorax

Guidelines on spontaneous pneumothorax are contradictory as to intervention between needle aspiration (NA) and chest tube drainage (CTD). Studies show poor adherence to guidelines.

Three Norwegian hospitals included patients with primary (PSP) and secondary (SSP) spontaneous pneumothorax. Patients underwent NA or CTD as the primary intervention. The main outcome was duration of hospital stay. Secondary outcomes were immediate- and 1-week success rates and complications.

127 patients were included, including 48 patients with SSP. 65 patients underwent NA, 63 patients CTD. Median (interquartile range) hospital stay was significantly shorter for NA: 2.4 days (1.2–4.7 days), compared with CTD: 4.6 days (2.3–7.8 days) (p<0.001). The corresponding figures for the SSP subgroup were 2.54 days (1.17–7.79 days) compared with 5.53 days (3.65–9.21 days) (p=0.049) for NA and CTD, respectively. Immediate success rates were 69% for NA compared with 32% for CTD (p<0.001). The positive effect of NA remained significant in sub-analyses for SSP. There was no significant difference in 1-week success rates. Complications occurred only during the CTD-treatment.

Our study shows shorter hospital stay and higher immediate success rates for NA compared with CTD. Subgroup analyses also show clear benefits for NA for both PSP and SSP.

The Size of Spontaneous Pneumothorax is a Predictor of Unsuccessful Catheter Drainage

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.

Presenting hydrothorax predicts failure of needle aspiration in primary spontaneous pneumothorax

OBJECTIVE

The objective was to evaluate if existence of hydrothorax in initial chest radiograph predicts treatment outcome in patients with primary spontaneous pneumothorax who received needle thoracostomy.

METHODS

This is a retrospective cohort study carried out from January 2011 to August 2014 in 1 public hospital in Hong Kong. All consecutive adult patients aged 18years or above who attended the emergency department with the diagnosis of primary spontaneous pneumothorax with needle aspiration performed as primary treatment were included. Age, smoking status, size of pneumothorax, previous history of pneumothorax, aspirated gas volume and presence of hydropneumothorax in initial radiograph were included in the analysis. The outcome was success or failure of the needle aspiration. Logistic regression was used to identify the predicting factors of failure of needle aspiration.

RESULT

There were a total of 127 patients included. Seventy-three patients (57.5%) were successfully treated with no recurrence upon discharge. Among 54 failure cases, 13 patients (10.2%) failed immediately after procedure as evident by chest radiograph and required second treatment. Forty-one patients (32.3%) failed upon subsequent chest radiographs. Multivariate logistic regression showed factors independently associated with the failure of needle aspiration, which included hydropneumothorax in the initial radiograph (odds ratio [OR]=4.47 [1.56i12.83], P=.005), previous history of pneumothorax (OR=3.92 [1.57-9.79], P=.003), and large size of pneumothorax defined as apex-to-cupola distance ≥5cm (OR=2.75 [1.21-6.26], P=.016).

CONCLUSIONS

Hydropneumothorax, previous history of pneumothorax, and large size were independent predictors of failure of needle aspiration in treatment of primary spontaneous pneumothorax.

[Treatment of the first episode of spontaneous pneumothorax]

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%).

Management of paediatric spontaneous pneumothorax: a multicentre retrospective case series

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.

Three-step management of pneumothorax: time for a re-think on initial management

Pneumothorax is a common disease worldwide, but surprisingly, its initial management remains controversial. There are some published guidelines for the management of spontaneous pneumothorax. However, they differ in some respects, particularly in initial management. In published trials, the objective of treatment has not been clarified and it is not possible to compare the treatment strategies between different trials because of inappropriate evaluations of the air leak. Therefore, there is a need to outline the optimal management strategy for pneumothorax. In this report, we systematically review published randomized controlled trials of the different treatments of primary spontaneous pneumothorax, point out controversial issues and finally propose a three-step strategy for the management of pneumothorax. There are three important characteristics of pneumothorax: potentially lethal respiratory dysfunction; air leak, which is the obvious cause of the disease; frequent recurrence. These three characteristics correspond to the three steps. The central idea of the strategy is that the lung should not be expanded rapidly, unless absolutely necessary. The primary objective of both simple aspiration and chest drainage should be the recovery of acute respiratory dysfunction or the avoidance of respiratory dysfunction and subsequent complications. We believe that this management strategy is simple and clinically relevant and not dependent on the classification of pneumothorax.

Benefits from apical chest tube drainage in pneumothorax

Pneumothorax is the accumulation of air in the pleural space. Pneumothorax may occur spontaneously (primary spontaneous pneumothorax, PSP). Chest tube drainage (CTD) is the most common choice for treatment of PSP. This study aimed to evaluate patients treated with CTD, regarding demographic and diagnostic characteristics, and to compare the effectiveness of apical and axillary approaches. We retrospectively analyzed a total of 217 patients with PSP regarding symptoms, duration of complaints, and treatment procedures. There were 196 (90.3%) male patients and mean age was 25.22 ± 5.37 years. The approach of CTD was determined randomly; being performed with the apical approach on 93 (42.9%) and axillary on 124 patients (57.1%). There were no statistically significant differences between the two groups in terms of age, sex, BMI, collapse size, and complaint duration. However, a statistically significant relationship was determined between collapse size and leading symptoms where the significance was related to dyspnea (p < 0.001). This led to the thought that dyspnea increases with the increase of collapse size. The patients who were admitted to hospital in the later term when compared with others, had a larger collapse size (p < 0.001). This also led to the thought that collapse increases in relation to time due to late admission of patients. Hospitalization time was significantly shorter in patients who had apical CTD (p < 0.001). In conclusion, inserting the tube from the apex could shorten the treatment period.

Evidence-based management of paediatric primary spontaneous pneumothorax

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.

Salvage for unsuccessful aspiration of primary pneumothorax: thoracoscopic surgery or chest tube drainage?

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.

Review of management of primary spontaneous pneumothorax: is the best evidence clearer 15 years on?

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.

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

BACKGROUND

In the management of primary spontaneous pneumothorax, simple aspiration is technically easier to perform. A systematic review may better define the clinical effectiveness and safety of simple aspiration compared to intercostal tube drainage in the management of primary spontaneous pneumothorax.

OBJECTIVES

To compare the clinically efficacy and safety of simple aspiration and intercostal tube drainage in the management of primary spontaneous pneumothorax.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2006), MEDLINE (1966 to August 2006), and EMBASE (1980 to August 2006). We searched Current Controlled Trials metaRegister of Clinical Trials (compiled by Current Science) (August 2006). We checked the reference lists of trials and contacted trial authors . We imposed no language restriction.

SELECTION CRITERIA

Randomized controlled trials comparing simple aspiration with intercostal tube drainage in adults aged 18 and over with primary spontaneous pneumothorax.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. No statistical methods were necessary because only one study met the inclusion criteria.

MAIN RESULTS

Of the 1239 publications obtained from the search strategy, we examined six studies. Five studies were excluded, and one study of 60 participants was eligible for inclusion. There was no difference in immediate success rate of simple aspiration when compared with intercostal tube drainage in the management of primary spontaneous pneumothorax (relative risk (RR) = 0.93; 95% confidence interval (CI) 0.62 to 1.40). There was no significant difference in the early failure rate between the two interventions: RR 1.12 (95% CI 0.59 to 2.13). Simple aspiration reduced the proportion of patients hospitalized (RR = 0.52; 95% CI 0.36 to 0.75). There was no significant difference between the two interventions with regard to the following outcome measures: duration of hospitalization (weighted mean difference = 1.09; 95% CI 2.18 to 0.00); number of participants undergoing any procedure for lung pleurodesis within one year (RR = 0.95; 95% CI 0.41 to 2.22);and one year success rate (RR = 1.02; 95% CI 0.75 to 1.38).

AUTHORS' CONCLUSIONS

There is no significant difference between simple aspiration and intercostal tube drainage with regard to: immediate success rate, early failure rate, duration of hospitalisation, one year success rate and number of patients requiring pleurodesis at one year. Simple aspiration is associated with a reduction in the per cent of patients hospitalized when compared with intercostal tube drainage.

Quality Initiative in Rectal Cancer Strategy: A Qualitative Study of Participating Surgeons

BACKGROUND

The Quality Initiative in Rectal Cancer (QIRC) Strategy randomized 16 hospitals across Ontario to the QIRC strategy versus minimal intervention. The strategy included a workshop, recruitment of a local opinion leader (OL), operative demonstrations, postoperative checklists, audit, and feedback. Surgeons at each intervention hospital used a standardized approach to select a local OL from their ranks. We assessed the experiences of OL and non-OL surgeons in the QIRC strategy.

STUDY DESIGN

Semi-structured qualitative telephone interviews were completed with 8 OLs and 8 non-OL surgeons. Interviews were guided by Grounded Theory. Initial interviews were assessed to ensure that domains of interest were fully explored. Two investigators (FW, MF) independently reviewed all final transcripts and identified themes. Consensus among all investigators was achieved for final themes.

RESULTS

All approached surgeons participated in interviews. Seven themes were identified: surgical OLs with subspecialist expertise were supported; surgical OL requires technical expertise; limited role for local OL on changing physician practice in rectal cancer operations; limited effect of identifying local OL on local interactions; operative demonstrations supported; characteristics of operative demonstrator were important; and perceived positive effect of the QIRC strategy on practice.

CONCLUSIONS

The experience of local OLs in this trial appears to be mixed. Although some of the themes support the concept of a local OL, other themes suggest the local OL had a limited role and effect. The overall QIRC strategy, and in particular the operative demonstration, was viewed positively and was perceived to have a positive longterm effect on participants' practice.

The Accident and Emergency Department Virtual Consulting Room

The goal was to describe the development of the Virtual Consulting Room (VcR), a unique intranet-based guidance application providing direct access to local specialist knowledge, and to evaluate its usability and whether it has the potential to educate staff while working in the Accident and Emergency (A&E) department. Duty staff of the A&E Department, The Royal Free Hospital, London, participated in a prospective observational study. Two hundred and twenty consecutive patients were identified from the triage section of their casualty card as having a presenting complaint that featured in the VcR. These casualty cards were highlighted with a red sticker alert and a short questionnaire attached. Members of staff were invited to consult with the VcR after assessing each patient by clicking on an icon located on the department's computer desktops. No prior training was provided. The questionnaire was completed in 103 of 220 (46.8%) patients. The VcR was used in the management of 38 of 220 (17.3%) patients. In 21 of 38 (55.3%), users reported the VcR supported clinical decision making, in 20 of 38 (52.6%) the VcR improved knowledge and in 11 of 38 (28.9%) the VcR helped directly influence the decision to discharge the patient. In 2 of 38 (5.3%) users changed their decision to refer and in 1 of 38 (2.6%) investigations were altered. This evaluation indicates that A&E clinicians accessing the VcR found it easy to use and educational in the workplace.

Management of spontaneous pneumothorax

Management of patients with a spontaneous pneumothorax continues to challenge clinicians. Recent guidelines help provide care pathways for these patients and highlight the many areas in need of additional study. Management options for spontaneous pneumothoraces should be selected based primarily upon a patient's clinical status. Observation or pleural air drainage, in selected patients, plays a significant role in patients with primary spontaneous pneumothorax. By contrast, pleural air drainage plays the central role in patients with a secondary spontaneous pneumothorax. Surgically directed recurrence prevention and air leak management are preferred for both primary and secondary spontaneous pneumothorax patients.

A blended knowledge translation initiative to improve colorectal cancer staging [ISRCTN56824239]

BACKGROUND

A significant gap has been documented between best practice and the actual practice of surgery. Our group identified that colorectal cancer staging in Ontario was suboptimal and subsequently developed a knowledge translation strategy using the principles of social marketing and the influence of expert and local opinion leaders for colorectal cancer.

METHODS/DESIGN

Opinion leaders were identified using the Hiss methodology. Hospitals in Ontario were cluster-randomized to one of two intervention arms. Both groups were exposed to a formal continuing medical education session given by the expert opinion leader for colorectal cancer. In the treatment group the local Opinion Leader for colorectal cancer was detailed by the expert opinion leader for colorectal cancer and received a toolkit. Forty-two centres agreed to have the expert opinion leader for colorectal cancer come and give a formal continuing medical education session that lasted between 50 minutes and 4 hours. No centres refused the intervention. These sessions were generally well attended by most surgeons, pathologists and other health care professionals at each centre. In addition all but one of the local opinion leaders for colorectal cancer met with the expert opinion leader for colorectal cancer for the academic detailing session that lasted between 15 and 30 minutes.

DISCUSSION

We have enacted a unique study that has attempted to induce practice change among surgeons and pathologists using an adapted social marketing model that utilized the influence of both expert and local opinion leaders for colorectal cancer in a large geographic area with diverse practice settings.

Simple aspiration as initial treatment for primary spontaneous pneumothorax: Results of 91 consecutive cases

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.

Pneumothorax

Spontaneous pneumothoraces can occur without obvious underlying lung disease (primary) or in patients with known underlying lung disease (secondary). Management guidelines for spontaneous pneumothorax have been published by major professional organizations, but awareness and application among clinicians seems poor. First episodes of primary spontaneous pneumothorax can be managed with observation if the pneumothorax is small. If the pneumothorax is large or if the patient is symptomatic, manual aspiration via a small catheter or insertion of a small-bore catheter coupled to a Heimlich valve or water-seal device, should be performed. In general, definitive measures to prevent recurrence are recommended after the first recurrence of the pneumothorax, and can be achieved by medical (e.g. talc) or surgical (video-assisted thoracic surgery) pleurodesis. Secondary pneumothoraces should be treated with chest tube drainage followed by pleurodesis after the first episode to minimize any risk of recurrence. Traumatic pneumothoraces may be occult (not seen on an initial CXR) or non-occult. The majority are treated by placement of a chest tube. Selected patients may be treated conservatively, with approximately 10% of these patients eventually requiring chest tube placement. Iatrogenic pneumothoraces have a myriad of causes with transthoracic lung needle biopsy being most common. Transthoracic needle biopsy-related pneumothoraces have CT findings that can predict their occurrence and the need for chest tube placement. Iatrogenic pneumothoraces, regardless of cause, may be managed by observation or small bore chest tube placement, depending upon patient stability and the size of the pneumothorax.

Spontaneous Pneumothorax Outcome Study (SPOT phase I): a 2-year review

OBJECTIVE

We aim to describe the incidence of spontaneous pneumothorax presenting to the Emergency Department, the treatment given and the outcomes of treatment.

METHODS

We conducted a retrospective review of patients with spontaneous pneumothorax presenting to the Emergency Department of the Singapore General Hospital from 1 January 2000 to 31 December 2001.

RESULTS

Of a total of 159 patients, with a mean age of 36.1 years (standard deviation 19.3), 94.3% were men, 75 (47.2%) were treated in the Emergency Department with chest-tube insertion, 28 (17.6%) were treated with needle aspiration, and 56 (35.2%) were observed. Significantly more patients had complete re-expansion with chest-tube (65.3%) compared with needle aspiration (17.9%) (P<0.001). Patients with needle aspiration or those being observed were more likely to have a second procedure (P<0.001), whereas patients with chest tubes were more likely to have definitive treatment subsequently (pleurodesis, thoracotomy). The mean duration of hospitalization was significantly longer for chest-tube insertion (7.4 days) compared with other groups (needle aspiration 4 days). There was no significant difference in the complication rates between treatment groups at one year.

CONCLUSION

We found a male predominance locally. Treatment with chest-tube insertion is still the most popular method in the Emergency Department. Needle aspiration results in a shorter hospitalization, but a high proportion require a second procedure. Complication rates do not seem to differ from chest-tube insertion.

Management of primary spontaneous pneumothorax

The optimal management of primary spontaneous pneumothorax remains the subject of considerable controversy. During the last few years, however, interesting new data on pathogenesis and various treatment techniques have been published, which have led to the publication of some interesting and thought-provoking opinion articles. The author reviews the latest developments in pneumothorax pathophysiology and management.