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Presenting hydrothorax predicts failure of needle aspiration in primary spontaneous pneumothorax
Presenting hydrothorax predicts failure of needle aspiration in primary spontaneous pneumothorax Kwok Kei Wu MCEM, Chun Tat Lui FHKAM(Emergency Medicine), Chik Leung Ho FHKAM(Emergency Medicine), Kwok Leung Tsui FHKAM(Emergency Medicine), Hin Tat Fung FHKAM(Emergency Medicine) PII: DOI: Reference:
S0735-6757(16)00205-9 doi: 10.1016/j.ajem.2016.03.023 YAJEM 55672
To appear in:
American Journal of Emergency Medicine
Received date: Revised date: Accepted date:
30 December 2015 8 March 2016 8 March 2016
Please cite this article as: Wu Kwok Kei, Lui Chun Tat, Ho Chik Leung, Tsui Kwok Leung, Fung Hin Tat, Presenting hydrothorax predicts failure of needle aspiration in primary spontaneous pneumothorax, American Journal of Emergency Medicine (2016), doi: 10.1016/j.ajem.2016.03.023
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Title: Presenting hydrothorax predicts failure of needle aspiration in primary spontaneous pneumothorax KK Wu *, CT Lui *, CL Ho, KL Tsui, HT Fung
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Word count: 2354 highest academic degrees
e-mail addresses
institutional affiliations
Kwok Kei Wu
MCEM
[email protected]
Resident,
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full first and last names
FHKAM(Emergency Medicine)
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Chun Tat Lui
FHKAM(Emergency Medicine)
Kwok Leung Tsui
FHKAM(Emergency Medicine)
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Hin Tat Fung
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Chik Leung Ho
FHKAM(Emergency Medicine)
[email protected]
Department of A&E, Tuen Mun Hospital Associate consultant, Department of A&E, Tuen Mun Hospital
[email protected]
Resident, Department of A&E, Tuen Mun Hospital
[email protected]
Senior medical officer, Department of A&E, Tuen Mun Hospital
[email protected]
Consultant, Department of A&E, Tuen Mun Hospital
Last name underlined * Dr KK Wu and Dr CT Lui and equivalent contribution to the article and would be listed as co- first authors. All authors did not have any personal or financial support or author involvement with organization(s) with financial interest in the subject matter, or any conflict of interest.
ACCEPTED MANUSCRIPT Correspondence to: Dr CT Lui (E-mail: [email protected]) Department of Accident and Emergency Medicine,
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Tuen Mun Hospital, Tsing Chung Koon Road, Tuen Mun, N.T., HKSAR
The study was conducted in Department of Accident and Emergency Medicine,
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Tuen Mun Hospital, HKSAR
ACCEPTED MANUSCRIPT Abstract
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Objective: To evaluate if existence of hydrothorax in initial chest X-ray predict treatment outcome in patients with primary spontaneous pneumothorax received needle thoracostomy.
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Methods: This is a retrospective cohort study carried out from January 2011 to August 2014 in one public hospital in Hong Kong. All consecutive adult patients aged 18 years or above who attended the emergency department with the diagnosis of primary spontaneous pneumothorax with needle aspiration was performed as primary treatment were included. Age, smoking status, size of
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pneumothorax, previous history of pneumothorax, aspirated gas volume and presence of hydropneumothorax in initial X-ray were included in the analysis. The outcome was successful or failure of the needle aspiration. Logistic regression was used to identify the predicting factors of failure of needle aspiration.
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Result: There were totally 127 patients included. 73 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 X-ray that require second treatment. 41 patients (32.3%) failed upon
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subsequent chest X-rays. Multivariate logistic regression showed factors independently associated with the failure of needle aspiration, which included hydropneumothorax in the initial X-ray (OR=4.47 [1.56 – 12.83], p=0.005), previous history of pneumothorax (OR=3.92 [1.57-9.79], p=0.003) and large size of pneumothorax defined as apex-to-cupola disease ≥ 5cm (OR=2.75 [1.21-6.26], p=0.016).
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Conclusions: Hydropneumothorax, previous history of pneumothorax and large size were independent predictors of failure of needle aspiration in treatment of primary spontaneous pneumothorax. Keywords: Hydropneumothorax, pleural effusion, treatment failure, treatment outcome
ACCEPTED MANUSCRIPT Introduction
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Primary spontaneous pneumothorax (PSP) is a common medical condition encountered in emergency departments. It occurs in patient with no evidence of other underlying pulmonary disease1. It is believed to result from blebs or from other abnormalities of the pleural surface2,3. Some study suggested change in atmospheric pressure is associated with the occurrence in primary spontaneous pneumothorax4. The exact mechanism of the spontaneous pneumothorax remains unknown5.
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Needle aspiration was advocated by international guidelines as the initial intervention for PSP 6,7. It
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is considered as a less painful and less invasive procedure as compared to conventional chest drain insertion. It showed similar successful rate ranging from 30-80% 7. Needle aspiration was increasingly adopted as the initial treatment for selected group of patients with pneumothorax in Hong Kong. Needle aspiration was considered failure when there is persistent air leak and failure of pulmonary re-expansion. Various factors had been proposed to predict persistent air leak for patients with PSP. Small amount of hydrothorax in the presenting chest X-ray, presented with blunted costo-phrenic angle, was not uncommonly seen in patients with PSP (Figure 1). In those patients, no significant pleural effusion was observed after pulmonary re-expansion without drainage of pleural
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fluid. We observed that presence of hydropneumothorax in the presenting chest X-ray (CXR) is associated with higher failure rate of needle aspiration. In our study, we try to assess this association in a retrospective cohort.
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Method A retrospective cohort study was performed in the emergency department (ED) of one of the regional hospitals in Hong Kong. All patients aged 18 or more attended the ED from 1st January, 2011 to 30th August 2014 who was diagnosed primary pneumothorax. Needle aspiration was performed in all the included cases. All cases were retrieved by the electronic clinical data analysis and retrieval system with ICD-9 code 512.0 (spontaneous pneumothorax) and 512.8 (spontaneous tension pneumothorax). Traumatic pneumothorax, secondary pneumothorax with pre-existing respiratory disease and wrong diagnosis were excluded. Patients with hydropneumothorax with significant residual pleural effusion after drainage, or other findings of underlying lung pathologies were excluded. Patients with lung pathologies identified after one year of follow-up that may be accountable for the pleural effusion in the initial CXR were also excluded. The written and electronic patient record, past medical history and the chest X-ray were retrieved and analyzed. PSP is defined as spontaneous pneumothorax in person without underlying lung disease1. Patient characteristic including age, gender, smoking status, previous history of pneumothorax, symptom onset to time of aspiration, size of the pneumothorax, aspirated gas volume, presence of hydropneumothorax and the side of pneumothorax, were investigated.
ACCEPTED MANUSCRIPT The size of pneumothorax was measured through digital radiography. The apex-to-cupola distance
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and the interpleural distance at mid hilum level were measured. Signs of mediastinal compression were defined as near complete pulmonary collapse in chest X-ray with heart rate drop by 20beats/min after decompression were recorded. Symptom onset to aspiration time was defined as the onset of symptoms of pleuritic chest pain or dyspnea to the time of needle aspiration.
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Needle aspiration was performed at the second intercostal or third intercostal space at mid clavicular line in the affected side. Primary outcome was successful needle aspiration. It is defined as no further procedures required, which include repeated needle aspiration, chest drain insertion or pleurodesis. Patients who had failed pulmonary re-expansion after needle aspiration was defined as
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immediate failure. Pneumothorax developed again within 4 weeks of index admission was defined as recurrence and delay failure. The medical records were traced for at least one year for patients with hydrothorax in presentation to detect any lung pathologies noticed in subsequent period.
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Baseline characteristic was described using descriptive statistics. Categorical variables were shown as frequencies and percentages. They were compared with chi-squared test or Fisher exact test when appropriate. Continuous variables with standard distribution were showed as mean and standard derivation. For continuous variables with skewed distribution, median and interquatile range were
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shown respectively. There were compared with independent sample t-test or median test depending on the distribution. Relevant predicators of successful needle aspiration were sorted out. They were entered into a binominal logistic regression for confounding control if p<0.1 in univariate analysis. Adjusted odd ratios and confidence intervals were reported. Hosmer-and-Lemeshow test was employed in assessing model calibration and goodness-of-fit. Data analysis was performed by using SPSS version 22.0 for Windows (Armonk, NY: IBM Corp.). Statistical significance was accepted as a p<0.05. Ethics approval was obtained from the local institutional review board (IRB number NTWC/CREC/15120).
Result Total 373 cases of pneumothorax were retrieved from the database. 241 cases were primary pneumothorax. 127 (52.7%) of PSP cases undergoes needle aspiration as primary treatment. 84 (34.9%) had been conservative managed with oxygen alone. 30 (12.4%) had chest drain insertion. For those who received needle aspiration as primary treatment, the outcomes were shown in Figure 2. Around one fifth of the cases had initial small amount of hydrothorax in the presenting X-rays. None of them had been identified significant lung pathologies after one year of follow-up. Univariate analysis of treatment outcome was listed in Table 1. Different variables were comparable between successful and failed group, including age, gender, smoking status, presenting vitals and symptom onset to aspiration time. There was significant difference between two groups in size of pneumothorax, hydropneumothorax in initial X-ray, sign of mediastinal compression and previous
ACCEPTED MANUSCRIPT history of pneumothorax.
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Table 2 listed relevant variables which were entered into binominal logistic regression for confounding control. There were three significant independent predicators of failure of needle aspiration which included the presence of hydropneumothorax in initial chest X-ray (OR 4.47 [1.56-12.83], p=0.005), previous history of pneumothorax (OR 3.92 [1.57-9.79], p=0.003) and large pneumothorax with apex-to-cupola distance≥5cm (OR2.75 [1.21-6.26], p=0.016). Hosmer-and-Lemeshow test showed that the model demonstrated satisfactory goodness-of-fit.
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Discussion
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PSP is a common clinical condition encountered in emergency departments. Incidence was reported to be 18-28/100000 per annum for men and 1.2-6/100000 for woman7. Different approaches in treating this condition were postulated including active surgical management or conservative management9. Guideline by the British Thoracic Society in 2010 suggested needle aspiration as the initial intervention for PSP7. It had benefit on reducing hospitalization and length of hospital stay.
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In our study, hydropneumothorax on presentation was demonstrated to be an independent predictor
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of failure of needle aspiration with strong association (OR 4.47). This study is the first to report hydropneumothorax this association. There were case reports showing spontaneous hydropneumothorax associated with pulmonary tuberculosis, angiosacroma and pulmonary sarcoidosis10-12 but most presented with significant amount of pleural effusion. There was no documented pulmonary disease in all cases in the study and record tracing for a year. All patients with hydrothorax in presenting CXR had small amount of effusion (Figure 1). We had not examined the nature of pleural effusion, whenever they were transudative, exudative or hemothorax, due to limitation of the retrospective non-interventional study. From bedside experience on patients with PSP received chest drain insertion as the primary treatment, it was not uncommonly seen that small amount of blood-stained fluid drained. We hypothesized that the observation of small amount of hydrothorax in initial chest X-ray was in fact a small haemothorax. The presence of haemothorax may be related to underlying pathology of PSP. It is postulated that rupture of blebs is the cause of PSP 7. Pulmonary blebs are accumulation of air within the layer of visceral pleura, which is due to alveolar rupture in the subpleural layer13. The visceral pleura is a delicate serous membrane which is rich in blood supply. A relatively big rupture may tear larger amount of capillary vessels. It causes bleeding which contributed to the presence of a small haemothorax. The larger bleb rupture creates a larger defect which may contribute to persistent air leak and higher failure rate of needle aspiration. Most of the time in patients with normal haemostasis the bleeding was self-limiting. Furthermore, the higher intrapleural pressure in pneumothorax may provide tamponade effect on the ruptured vessel which may prevent further bleeding13. Another explanation of the hydrothorax may be impaired lymphatic flow in parietal pleura due to
ACCEPTED MANUSCRIPT increased pleural space pressure in pneumothorax. Pleural fluid is produced at parietal pleural level,
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mainly in the less dependent regions of the cavity, while reabsorption was accomplished by parietal pleural lymphatics in the most dependent part of the cavity, on the diaphragmatic surface and in the mediastinal regions14. The pleural fluid circulation keeps at equilibrium when the production of pleural fluid does not exceed the reabsorption rate. The effectiveness of pleural lymphatics may be jeopardized in pneumothorax when the pleural pressure is elevated. Hydrothorax in presenting CXR may be an indicator of high pleural pressure, which is not measured during needle aspiration. It would be interesting to know the clinical appearance and biochemistry of the subtle hydrothorax in a prospective study.
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Large pneumothorax was one of the significant predicators of failure in this study. The result was in line with previous studies15-19. The BTS guideline suggest to ceases needle aspiration after 2.5L of air has been aspirated7. Re-expansion is unlikely after 2.5L air aspirated due to persistent air leak20. Large pneumothorax in initial CXR probably increase the volume of air aspirated. It may also be related to persistent air leak due to underlying pathology.
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Symptom onset to needle aspiration time was suggested in one study to predict the outcome of needle aspiration15. It was hypothesized that needle aspiration performed before the closure of the
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communication between the alveolar space and the pleura may result in failure of needle aspiration. However, such finding was not reproducible in our study. This may be related to suboptimal documentation of onset time in this retrospective study. In our proportion, there was observation of higher proportion of failure for those with early aspiration (Table 1). But the difference did not reach statistical significance with limited sample size. A prospective study, with proper documentation of time of symptom onset and needle thoracostomy, and perhaps multi-centered with adequate sample size, would be required to confirm the casual relationship. Our study showed association between previous pneumothorax and failure of aspiration despite the side of previous pneumothorax. For the same side recurrent PSP, there were studies showed a higher recurrence rate after the first episode of PSP 21-23. But there were not enough clinical trial addressing the management of recurrent PSP24. The available studies suggest more aggressive and definite treatment of recurrent episode of PSP6. For the association of the opposite side, that may be related to the underlying cause of the pneumothorax7. Needle aspiration was recommended by the British Thoracic Society guideline as initial treatment of PSP with size >2cm. It is believed to be a safe procedure but it does not bear no risk. There was case report of massive haemothorax after needle aspiration of PSP25. Recently, there was advocate of conservative treatment in asymptomatic large size PSP26. The role of needle aspiration in recurrent, large sized pneumothorax needs further delineation. Besides needle aspiration, some experts advocate the use of small-bore catheter or pigtail catheter insertion for treatment of significant sized pneumothorax. However, there was no head-on-head comparison for the two
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Limitation of study
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This is a retrospective cohort study. The data were collected through electronic medical record system retrospectively and subject to information bias. Some essential information such as symptom onset time was missing. Data were collected from the period from 2011 onward as the needle aspiration had become one of the common primary treatment after the British Thoracic Society guideline in 2010 7.
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In measurement of apical-cupola distance and interpleural distance at mid hilum, the best available non-invasive method in measurement and calculation was computed tomography of thorax 27. We could only retrieve the CXR as surrogate marker due to the limitation of retrospective study. We define the recurrence as absence of second episode of pneumothorax within 4 weeks. There was a relatively short period of time. Also, the patient may not attend the same hospital again in the recurrent episode and we cannot trace the patient who had defaulted follow-up subsequently. There was potential bias of data loss in recurrence. Furthermore, those patients with hydrothorax in CXR
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may have underlying occult lung diseases that were not detected during the one year of follow-up record tracing, and the records were not traceable if patients attended in other private hospitals. And we did not have examination on the pleural fluid samples.
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Conclusions
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Presence of hydropneumothorax, previous history of pneumothorax and the large size of pneumothorax predict failure of needle aspiration of PSP. Acknowledgement
The original idea of research question was generated by Dr CT Lui. Dr KK Wu and Dr CL Ho were responsible for data entry, inclusion and exclusion, and data security. Dr CT Lui was responsible for statistical analysis, together with external statistical consultation. Dr KK Wu, Dr CT Lui, Dr KL Tsui and Dr HT Fung had primary contribution on the manuscript writing.
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References 1. Kjaergaard H. Spontaneous pneumothorax in the apparently healthy. Acta Med Scand 1932;43(Suppl):1-159. 2. Donahue DM, Wright CD, Viale G, Mathisen DJ. Resection of pulmonary blebs and pleurodesis for spontaneous pneumothorax. Chest 1993:104(6):1767-9. 3. Lesur O, Delorome N, Frogamet JM, Bermadac P, Polu JM. Computerd Tomography in the aetiological assessment of idiopathic spontaneous pneumothorax. Chest 1990;98(2):341-7. 4. Haga T, Kurihara M, Kataoka H, Ebana H. Influence of weather conditions on the onset of primary spontaneous pneumothorax: positive association with decrease in atmospheric pressure. Ann Thorac Cardiovasc Surg. 19(3); 212-5, 2013.
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5. Luca B, Andrea V, Lucia B, Antonello P, Alessandro A, Terzi A, et al. Analysis of spontaneous pneumothorax in the city of Cuneo: environmental correlations with meteorological and air pollutant variables. Surg Today 2015:45(5); 625-9. 6. Baumann MH, Strange C, Heffner JE, Light R, Kirby TJ, Klein J, et al and the AACP pneumothorax consensus group. Management of spontaneous pneumothorax and American College of Chest Physicans Delphi consensus statement. Chest 2001;119(2):590-602. 7. MacDuff A, Anthony A, John H, on behalf of the BTS Pleural Disease Guideline Group. Management of spontaneous pneumothorax: British Thoracic Society pleural disease
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guideline 2010; 65(suppl 2): ii18-31. 8. Andrivent P. Djedaim K, Teboul JL, Brochard L, Dreyfuss D. Spontaneous pneumothorax: comparison of thoracic drainage ve immediate or delay needle aspiration. Chest 1995;108(2):335-40. 9. Oliver JB, Rob JH, Anthony E, David FK, YC Lee, Charles HM, et al. Spontaneous pneumothorax: time to rethink management? Lancet Respir Med 2015;3(7):578-88. 10. Chang JH, Kim JH, Hong SH, Song ME, Ryu YJ, et al. Angiosacroma presenting with spontaneous hydropneumothorax: Report of a case and review of the literature. The Open Respiratory Medicine Journal 2014;8:48-54. 11. Baseem TD, Rajesh GP. Pulmonary Sarcoidosis: Presentation as bilateral spontaneous hydropneumothorax and pulmonary infilitrates. Southern Medical Journal 2000;93(5)494-96 12. Khajotia R, Kew ST, Cham YL. Left sided hydropneumothorax in a young male: Importance of clinical and radiological markers in arriving at an aetiological diagnosis. Malaysian Family Physician. 2009;4(1):41-43. 13. Shields TW. General thoracic surgery. Lippincott Williams & Wilkins 2009, ISBN0781779820. 14. Miserocchi G. Physiology and pathophysiology of pleural fluid turnover. Eur Respir J 1997;10(1):219-25. 15. 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 Med 2014;21(1):16-22. 16. Soulsby T. British Thoracic Society guidelines for the management of spontaneous
ACCEPTED MANUSCRIPT pneumothorax: do we comply with them and do they work? J Accid Emerg Med
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1998:15(5):317-21. 17. Archer GJ, Hamilton AA, Upadhyay R, Finlay M, Grace PM. Results of simple aspiration of pneumothoraces. Br J dis Chest 1985;79(2):177-82. 18. Mendis D,El-Shanawany T, Mathur A, Redington AE. Management of spontaneous pneumothorax: are British Thoracic Society guildlines being followed? Postgrad Med J 2002;78(916):80-4. 19. Chan SSW, Lam PKW. Simple aspiration as initial treatment for primary spontaneous pneumothorax: result of 91 consecutive case. J Emerg Med 2005;28(2):133-8. 20. Noppen M, Alexender P, Driesen P, Slabbynck H, Verstraeten A. Manual aspiration versus
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chest tube drainage in first episode primary spontaneous pneumothorax. Am J Respir Crit care Med 2002;165(9):1240-4. 21. Chan SSW, Timothy HR. Primary spontaneous pneumothorax: 1 year recurrence rate after simple aspiration. European Journal of Emergency Medicine 2006;13(2):88-91. 22. Devanand A, Koh MS, Ong TH, Low SY, Tan KL, et al. Simple aspiration versus chest tube insertion in the management of primary spontaneous pneumothorax: a systematic review. Respir Med 2004;98(7):579-90. 23. Harvey J, Prescott RJ. Simple aspiration versus intercostaltube drainage for spontaneous
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pneumothorax in patients with healthy lungs. Br Med J 1994;309:1338-9. 24. Zehtabchi S, Rios CL. Management of emergency department patients with primary spontaneous pneumothorax: needle aspiration or tube thoracostomy. Annals of Emergency Medicine 2008;51(1):91-100. 25. Rawlins R, Brown KM, Carr CS, Cameron CR. Life threatening haemorrhage after anterior needle aspiration of pneumothoraces. A role for lateral needle aspiration in emergency decompression of spontaneous pneumothorax. Emerg Med J 2003;20:383-4. 26. Kelly AM. Spontaneous pneumothorax: are we treating the X-ray or the patient? Hong Kong J. emerg. Med 2015;22(3):135-6. 27. Hoi K, Turchin B, Kelly AM. How accurate is the light index for estimating pneumothorax size? Austral Radiol 2007;51(12):196-8.
ACCEPTED MANUSCRIPT Table 1
Characteristics and predictors for successful needle aspiration for primary
spontaneous pneumothorax All
Successful
Failed
(n=127)
aspiration
aspiration
(n=73)
(n=54)
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Parameters
24.9 ± 10.3
23.5 ± 8.3
Male gender
114 (89.5%)
67 (91.8%)
47 (87%)
0.394
Active smoker
42 (53.1%)
23 (31.5%)
19 (35.2%)
0.663
70 (55.1%)
41 (56.2%)
29 (53.7%)
57 (44.9%)
32 (43.8%)
25 (46.3%)
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Age, mean ± SD
Right
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Previous pneumothorax
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Side of pneumothorax Left
26.7 ± 12.3
p value
0.219
0.783
25 (19.7%)
12 (16.4%)
13 (24.1%)
0.285
12 (9.4%)
2 (2.7%)
10 (18.5%)
0.004 #
33 (26%)
13 (17.8%)
20 (37%)
0.015
24 ± 43
24 ± 41.5
24 ± 25.6
0.626 *
34 (26.8%)
18 (24.7%)
16 (29.6%)
0.532
55 (43.3%)
32 (43.8%)
23 (42.6%)
0.889
90 (70.9%)
50 (68.5%)
40 (74.1%)
0.494
127 ± 18
128 ± 17
127 ± 18
0.683
73 ± 14
74 ± 13
72 ± 14
0.757
92 ± 63
87 ± 18
100 ± 94
0.644
99 ± 1.2
99 ± 1.2
98 ± 1.2
0.231
19 ± 3
18 ± 3
19 ± 2.8
0.272
43 ± 27
41 ± 24
50.5 ± 36.8
0.006 *
11 ± 16
9 ± 13.5
15.5 ± 17.0
0.003 *
Apex to cupola distance ≥ 50 mm
52 (40.9%)
23 (31.5%)
29 (53.7%)
0.012
Interpleural distance ≥ 30 mm
17 (13.4%)
7 (9.6%)
10 (18.5%)
0.144
Hydropneumothorax in initial chest X-ray
26 (20.5%)
8 (11%)
18 (33.3%)
0.003 #
Signs of mediastinal compression
8 (6.3%)
2 (2.7%)
6 (11.1%)
0.071 #
780 ± 740
690 ± 558
1015 ± 930
0.002 *
Aspirated volume ≥ 1000 ml
43 (33.9%)
16 (31.9%)
27 (50%)
0.001
Aspirated volume ≥ 2500 ml
17 (13.4%)
3 (4.1%)
14 (25.9%)
< 0.001 #
In same side In opposite side Any side Interval from symptom onset to aspirate Median ± IQR, hours
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Within 6 hours Within 12 hours
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Within 24 hours Presenting vital signs (mean ± SD)
Systolic blood pressure, mmHg
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Diastolic blood pressure, mmHg Heart rate, beats per minute
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SpO2 on room air, %
Respiratory rate, breaths per minute Size of pneumothorax (median ± IQR) Apex to cupola distance, mm Interpleural distance at hilum, in mm
(near-complete pulmonary collapse in X-ray + heart rate drop ≥ 20 /min after decompression) Aspirated volume Median ± IQR, in ml
ACCEPTED MANUSCRIPT 1±1
Length of stay, median± IQR, in days Failure of needle aspiration
1±0
3±7
--
--
13 (10.2%)
Immediate failure
41 (32.3%)
Delayed failure
# fisher’s exact test
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* independent sample median test
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ACCEPTED MANUSCRIPT Table 2 Logistic regression predicting failure of needle aspiration Adjusted odds ratio (95% CI)
p value
Hydropneumothorax on presentation Signs of mediastinal compression Large pneumothorax (apex to cupola distance ≥ 5cm) Previous pneumothorax
4.47 (1.56 - 12.83)
0.005
1.2 (0.19 - 7.57) 2.75 (1.21 - 6.26)
0.846 0.016
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Predictors
0.003
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3.92 (1.57 - 9.79)
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Patient presented with hydropneumothorax
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Figure 1
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Outcome of patients with PSP received needle aspiration as primary treatment
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Figure 2
S0735-6757(16)00205-9 doi: 10.1016/j.ajem.2016.03.023 YAJEM 55672
To appear in:
American Journal of Emergency Medicine
Received date: Revised date: Accepted date:
30 December 2015 8 March 2016 8 March 2016
Please cite this article as: Wu Kwok Kei, Lui Chun Tat, Ho Chik Leung, Tsui Kwok Leung, Fung Hin Tat, Presenting hydrothorax predicts failure of needle aspiration in primary spontaneous pneumothorax, American Journal of Emergency Medicine (2016), doi: 10.1016/j.ajem.2016.03.023
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Title: Presenting hydrothorax predicts failure of needle aspiration in primary spontaneous pneumothorax KK Wu *, CT Lui *, CL Ho, KL Tsui, HT Fung
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Word count: 2354 highest academic degrees
e-mail addresses
institutional affiliations
Kwok Kei Wu
MCEM
[email protected]
Resident,
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full first and last names
FHKAM(Emergency Medicine)
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Chun Tat Lui
FHKAM(Emergency Medicine)
Kwok Leung Tsui
FHKAM(Emergency Medicine)
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Hin Tat Fung
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Chik Leung Ho
FHKAM(Emergency Medicine)
[email protected]
Department of A&E, Tuen Mun Hospital Associate consultant, Department of A&E, Tuen Mun Hospital
[email protected]
Resident, Department of A&E, Tuen Mun Hospital
[email protected]
Senior medical officer, Department of A&E, Tuen Mun Hospital
[email protected]
Consultant, Department of A&E, Tuen Mun Hospital
Last name underlined * Dr KK Wu and Dr CT Lui and equivalent contribution to the article and would be listed as co- first authors. All authors did not have any personal or financial support or author involvement with organization(s) with financial interest in the subject matter, or any conflict of interest.
ACCEPTED MANUSCRIPT Correspondence to: Dr CT Lui (E-mail: [email protected]) Department of Accident and Emergency Medicine,
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Tuen Mun Hospital, Tsing Chung Koon Road, Tuen Mun, N.T., HKSAR
The study was conducted in Department of Accident and Emergency Medicine,
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Tuen Mun Hospital, HKSAR
ACCEPTED MANUSCRIPT Abstract
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Objective: To evaluate if existence of hydrothorax in initial chest X-ray predict treatment outcome in patients with primary spontaneous pneumothorax received needle thoracostomy.
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Methods: This is a retrospective cohort study carried out from January 2011 to August 2014 in one public hospital in Hong Kong. All consecutive adult patients aged 18 years or above who attended the emergency department with the diagnosis of primary spontaneous pneumothorax with needle aspiration was performed as primary treatment were included. Age, smoking status, size of
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pneumothorax, previous history of pneumothorax, aspirated gas volume and presence of hydropneumothorax in initial X-ray were included in the analysis. The outcome was successful or failure of the needle aspiration. Logistic regression was used to identify the predicting factors of failure of needle aspiration.
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Result: There were totally 127 patients included. 73 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 X-ray that require second treatment. 41 patients (32.3%) failed upon
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subsequent chest X-rays. Multivariate logistic regression showed factors independently associated with the failure of needle aspiration, which included hydropneumothorax in the initial X-ray (OR=4.47 [1.56 – 12.83], p=0.005), previous history of pneumothorax (OR=3.92 [1.57-9.79], p=0.003) and large size of pneumothorax defined as apex-to-cupola disease ≥ 5cm (OR=2.75 [1.21-6.26], p=0.016).
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Conclusions: Hydropneumothorax, previous history of pneumothorax and large size were independent predictors of failure of needle aspiration in treatment of primary spontaneous pneumothorax. Keywords: Hydropneumothorax, pleural effusion, treatment failure, treatment outcome
ACCEPTED MANUSCRIPT Introduction
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Primary spontaneous pneumothorax (PSP) is a common medical condition encountered in emergency departments. It occurs in patient with no evidence of other underlying pulmonary disease1. It is believed to result from blebs or from other abnormalities of the pleural surface2,3. Some study suggested change in atmospheric pressure is associated with the occurrence in primary spontaneous pneumothorax4. The exact mechanism of the spontaneous pneumothorax remains unknown5.
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Needle aspiration was advocated by international guidelines as the initial intervention for PSP 6,7. It
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is considered as a less painful and less invasive procedure as compared to conventional chest drain insertion. It showed similar successful rate ranging from 30-80% 7. Needle aspiration was increasingly adopted as the initial treatment for selected group of patients with pneumothorax in Hong Kong. Needle aspiration was considered failure when there is persistent air leak and failure of pulmonary re-expansion. Various factors had been proposed to predict persistent air leak for patients with PSP. Small amount of hydrothorax in the presenting chest X-ray, presented with blunted costo-phrenic angle, was not uncommonly seen in patients with PSP (Figure 1). In those patients, no significant pleural effusion was observed after pulmonary re-expansion without drainage of pleural
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fluid. We observed that presence of hydropneumothorax in the presenting chest X-ray (CXR) is associated with higher failure rate of needle aspiration. In our study, we try to assess this association in a retrospective cohort.
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Method A retrospective cohort study was performed in the emergency department (ED) of one of the regional hospitals in Hong Kong. All patients aged 18 or more attended the ED from 1st January, 2011 to 30th August 2014 who was diagnosed primary pneumothorax. Needle aspiration was performed in all the included cases. All cases were retrieved by the electronic clinical data analysis and retrieval system with ICD-9 code 512.0 (spontaneous pneumothorax) and 512.8 (spontaneous tension pneumothorax). Traumatic pneumothorax, secondary pneumothorax with pre-existing respiratory disease and wrong diagnosis were excluded. Patients with hydropneumothorax with significant residual pleural effusion after drainage, or other findings of underlying lung pathologies were excluded. Patients with lung pathologies identified after one year of follow-up that may be accountable for the pleural effusion in the initial CXR were also excluded. The written and electronic patient record, past medical history and the chest X-ray were retrieved and analyzed. PSP is defined as spontaneous pneumothorax in person without underlying lung disease1. Patient characteristic including age, gender, smoking status, previous history of pneumothorax, symptom onset to time of aspiration, size of the pneumothorax, aspirated gas volume, presence of hydropneumothorax and the side of pneumothorax, were investigated.
ACCEPTED MANUSCRIPT The size of pneumothorax was measured through digital radiography. The apex-to-cupola distance
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and the interpleural distance at mid hilum level were measured. Signs of mediastinal compression were defined as near complete pulmonary collapse in chest X-ray with heart rate drop by 20beats/min after decompression were recorded. Symptom onset to aspiration time was defined as the onset of symptoms of pleuritic chest pain or dyspnea to the time of needle aspiration.
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Needle aspiration was performed at the second intercostal or third intercostal space at mid clavicular line in the affected side. Primary outcome was successful needle aspiration. It is defined as no further procedures required, which include repeated needle aspiration, chest drain insertion or pleurodesis. Patients who had failed pulmonary re-expansion after needle aspiration was defined as
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immediate failure. Pneumothorax developed again within 4 weeks of index admission was defined as recurrence and delay failure. The medical records were traced for at least one year for patients with hydrothorax in presentation to detect any lung pathologies noticed in subsequent period.
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Baseline characteristic was described using descriptive statistics. Categorical variables were shown as frequencies and percentages. They were compared with chi-squared test or Fisher exact test when appropriate. Continuous variables with standard distribution were showed as mean and standard derivation. For continuous variables with skewed distribution, median and interquatile range were
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shown respectively. There were compared with independent sample t-test or median test depending on the distribution. Relevant predicators of successful needle aspiration were sorted out. They were entered into a binominal logistic regression for confounding control if p<0.1 in univariate analysis. Adjusted odd ratios and confidence intervals were reported. Hosmer-and-Lemeshow test was employed in assessing model calibration and goodness-of-fit. Data analysis was performed by using SPSS version 22.0 for Windows (Armonk, NY: IBM Corp.). Statistical significance was accepted as a p<0.05. Ethics approval was obtained from the local institutional review board (IRB number NTWC/CREC/15120).
Result Total 373 cases of pneumothorax were retrieved from the database. 241 cases were primary pneumothorax. 127 (52.7%) of PSP cases undergoes needle aspiration as primary treatment. 84 (34.9%) had been conservative managed with oxygen alone. 30 (12.4%) had chest drain insertion. For those who received needle aspiration as primary treatment, the outcomes were shown in Figure 2. Around one fifth of the cases had initial small amount of hydrothorax in the presenting X-rays. None of them had been identified significant lung pathologies after one year of follow-up. Univariate analysis of treatment outcome was listed in Table 1. Different variables were comparable between successful and failed group, including age, gender, smoking status, presenting vitals and symptom onset to aspiration time. There was significant difference between two groups in size of pneumothorax, hydropneumothorax in initial X-ray, sign of mediastinal compression and previous
ACCEPTED MANUSCRIPT history of pneumothorax.
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Table 2 listed relevant variables which were entered into binominal logistic regression for confounding control. There were three significant independent predicators of failure of needle aspiration which included the presence of hydropneumothorax in initial chest X-ray (OR 4.47 [1.56-12.83], p=0.005), previous history of pneumothorax (OR 3.92 [1.57-9.79], p=0.003) and large pneumothorax with apex-to-cupola distance≥5cm (OR2.75 [1.21-6.26], p=0.016). Hosmer-and-Lemeshow test showed that the model demonstrated satisfactory goodness-of-fit.
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Discussion
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PSP is a common clinical condition encountered in emergency departments. Incidence was reported to be 18-28/100000 per annum for men and 1.2-6/100000 for woman7. Different approaches in treating this condition were postulated including active surgical management or conservative management9. Guideline by the British Thoracic Society in 2010 suggested needle aspiration as the initial intervention for PSP7. It had benefit on reducing hospitalization and length of hospital stay.
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In our study, hydropneumothorax on presentation was demonstrated to be an independent predictor
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of failure of needle aspiration with strong association (OR 4.47). This study is the first to report hydropneumothorax this association. There were case reports showing spontaneous hydropneumothorax associated with pulmonary tuberculosis, angiosacroma and pulmonary sarcoidosis10-12 but most presented with significant amount of pleural effusion. There was no documented pulmonary disease in all cases in the study and record tracing for a year. All patients with hydrothorax in presenting CXR had small amount of effusion (Figure 1). We had not examined the nature of pleural effusion, whenever they were transudative, exudative or hemothorax, due to limitation of the retrospective non-interventional study. From bedside experience on patients with PSP received chest drain insertion as the primary treatment, it was not uncommonly seen that small amount of blood-stained fluid drained. We hypothesized that the observation of small amount of hydrothorax in initial chest X-ray was in fact a small haemothorax. The presence of haemothorax may be related to underlying pathology of PSP. It is postulated that rupture of blebs is the cause of PSP 7. Pulmonary blebs are accumulation of air within the layer of visceral pleura, which is due to alveolar rupture in the subpleural layer13. The visceral pleura is a delicate serous membrane which is rich in blood supply. A relatively big rupture may tear larger amount of capillary vessels. It causes bleeding which contributed to the presence of a small haemothorax. The larger bleb rupture creates a larger defect which may contribute to persistent air leak and higher failure rate of needle aspiration. Most of the time in patients with normal haemostasis the bleeding was self-limiting. Furthermore, the higher intrapleural pressure in pneumothorax may provide tamponade effect on the ruptured vessel which may prevent further bleeding13. Another explanation of the hydrothorax may be impaired lymphatic flow in parietal pleura due to
ACCEPTED MANUSCRIPT increased pleural space pressure in pneumothorax. Pleural fluid is produced at parietal pleural level,
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mainly in the less dependent regions of the cavity, while reabsorption was accomplished by parietal pleural lymphatics in the most dependent part of the cavity, on the diaphragmatic surface and in the mediastinal regions14. The pleural fluid circulation keeps at equilibrium when the production of pleural fluid does not exceed the reabsorption rate. The effectiveness of pleural lymphatics may be jeopardized in pneumothorax when the pleural pressure is elevated. Hydrothorax in presenting CXR may be an indicator of high pleural pressure, which is not measured during needle aspiration. It would be interesting to know the clinical appearance and biochemistry of the subtle hydrothorax in a prospective study.
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Large pneumothorax was one of the significant predicators of failure in this study. The result was in line with previous studies15-19. The BTS guideline suggest to ceases needle aspiration after 2.5L of air has been aspirated7. Re-expansion is unlikely after 2.5L air aspirated due to persistent air leak20. Large pneumothorax in initial CXR probably increase the volume of air aspirated. It may also be related to persistent air leak due to underlying pathology.
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Symptom onset to needle aspiration time was suggested in one study to predict the outcome of needle aspiration15. It was hypothesized that needle aspiration performed before the closure of the
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communication between the alveolar space and the pleura may result in failure of needle aspiration. However, such finding was not reproducible in our study. This may be related to suboptimal documentation of onset time in this retrospective study. In our proportion, there was observation of higher proportion of failure for those with early aspiration (Table 1). But the difference did not reach statistical significance with limited sample size. A prospective study, with proper documentation of time of symptom onset and needle thoracostomy, and perhaps multi-centered with adequate sample size, would be required to confirm the casual relationship. Our study showed association between previous pneumothorax and failure of aspiration despite the side of previous pneumothorax. For the same side recurrent PSP, there were studies showed a higher recurrence rate after the first episode of PSP 21-23. But there were not enough clinical trial addressing the management of recurrent PSP24. The available studies suggest more aggressive and definite treatment of recurrent episode of PSP6. For the association of the opposite side, that may be related to the underlying cause of the pneumothorax7. Needle aspiration was recommended by the British Thoracic Society guideline as initial treatment of PSP with size >2cm. It is believed to be a safe procedure but it does not bear no risk. There was case report of massive haemothorax after needle aspiration of PSP25. Recently, there was advocate of conservative treatment in asymptomatic large size PSP26. The role of needle aspiration in recurrent, large sized pneumothorax needs further delineation. Besides needle aspiration, some experts advocate the use of small-bore catheter or pigtail catheter insertion for treatment of significant sized pneumothorax. However, there was no head-on-head comparison for the two
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Limitation of study
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This is a retrospective cohort study. The data were collected through electronic medical record system retrospectively and subject to information bias. Some essential information such as symptom onset time was missing. Data were collected from the period from 2011 onward as the needle aspiration had become one of the common primary treatment after the British Thoracic Society guideline in 2010 7.
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In measurement of apical-cupola distance and interpleural distance at mid hilum, the best available non-invasive method in measurement and calculation was computed tomography of thorax 27. We could only retrieve the CXR as surrogate marker due to the limitation of retrospective study. We define the recurrence as absence of second episode of pneumothorax within 4 weeks. There was a relatively short period of time. Also, the patient may not attend the same hospital again in the recurrent episode and we cannot trace the patient who had defaulted follow-up subsequently. There was potential bias of data loss in recurrence. Furthermore, those patients with hydrothorax in CXR
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may have underlying occult lung diseases that were not detected during the one year of follow-up record tracing, and the records were not traceable if patients attended in other private hospitals. And we did not have examination on the pleural fluid samples.
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Conclusions
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Presence of hydropneumothorax, previous history of pneumothorax and the large size of pneumothorax predict failure of needle aspiration of PSP. Acknowledgement
The original idea of research question was generated by Dr CT Lui. Dr KK Wu and Dr CL Ho were responsible for data entry, inclusion and exclusion, and data security. Dr CT Lui was responsible for statistical analysis, together with external statistical consultation. Dr KK Wu, Dr CT Lui, Dr KL Tsui and Dr HT Fung had primary contribution on the manuscript writing.
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References 1. Kjaergaard H. Spontaneous pneumothorax in the apparently healthy. Acta Med Scand 1932;43(Suppl):1-159. 2. Donahue DM, Wright CD, Viale G, Mathisen DJ. Resection of pulmonary blebs and pleurodesis for spontaneous pneumothorax. Chest 1993:104(6):1767-9. 3. Lesur O, Delorome N, Frogamet JM, Bermadac P, Polu JM. Computerd Tomography in the aetiological assessment of idiopathic spontaneous pneumothorax. Chest 1990;98(2):341-7. 4. Haga T, Kurihara M, Kataoka H, Ebana H. Influence of weather conditions on the onset of primary spontaneous pneumothorax: positive association with decrease in atmospheric pressure. Ann Thorac Cardiovasc Surg. 19(3); 212-5, 2013.
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5. Luca B, Andrea V, Lucia B, Antonello P, Alessandro A, Terzi A, et al. Analysis of spontaneous pneumothorax in the city of Cuneo: environmental correlations with meteorological and air pollutant variables. Surg Today 2015:45(5); 625-9. 6. Baumann MH, Strange C, Heffner JE, Light R, Kirby TJ, Klein J, et al and the AACP pneumothorax consensus group. Management of spontaneous pneumothorax and American College of Chest Physicans Delphi consensus statement. Chest 2001;119(2):590-602. 7. MacDuff A, Anthony A, John H, on behalf of the BTS Pleural Disease Guideline Group. Management of spontaneous pneumothorax: British Thoracic Society pleural disease
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guideline 2010; 65(suppl 2): ii18-31. 8. Andrivent P. Djedaim K, Teboul JL, Brochard L, Dreyfuss D. Spontaneous pneumothorax: comparison of thoracic drainage ve immediate or delay needle aspiration. Chest 1995;108(2):335-40. 9. Oliver JB, Rob JH, Anthony E, David FK, YC Lee, Charles HM, et al. Spontaneous pneumothorax: time to rethink management? Lancet Respir Med 2015;3(7):578-88. 10. Chang JH, Kim JH, Hong SH, Song ME, Ryu YJ, et al. Angiosacroma presenting with spontaneous hydropneumothorax: Report of a case and review of the literature. The Open Respiratory Medicine Journal 2014;8:48-54. 11. Baseem TD, Rajesh GP. Pulmonary Sarcoidosis: Presentation as bilateral spontaneous hydropneumothorax and pulmonary infilitrates. Southern Medical Journal 2000;93(5)494-96 12. Khajotia R, Kew ST, Cham YL. Left sided hydropneumothorax in a young male: Importance of clinical and radiological markers in arriving at an aetiological diagnosis. Malaysian Family Physician. 2009;4(1):41-43. 13. Shields TW. General thoracic surgery. Lippincott Williams & Wilkins 2009, ISBN0781779820. 14. Miserocchi G. Physiology and pathophysiology of pleural fluid turnover. Eur Respir J 1997;10(1):219-25. 15. 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 Med 2014;21(1):16-22. 16. Soulsby T. British Thoracic Society guidelines for the management of spontaneous
ACCEPTED MANUSCRIPT pneumothorax: do we comply with them and do they work? J Accid Emerg Med
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1998:15(5):317-21. 17. Archer GJ, Hamilton AA, Upadhyay R, Finlay M, Grace PM. Results of simple aspiration of pneumothoraces. Br J dis Chest 1985;79(2):177-82. 18. Mendis D,El-Shanawany T, Mathur A, Redington AE. Management of spontaneous pneumothorax: are British Thoracic Society guildlines being followed? Postgrad Med J 2002;78(916):80-4. 19. Chan SSW, Lam PKW. Simple aspiration as initial treatment for primary spontaneous pneumothorax: result of 91 consecutive case. J Emerg Med 2005;28(2):133-8. 20. Noppen M, Alexender P, Driesen P, Slabbynck H, Verstraeten A. Manual aspiration versus
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chest tube drainage in first episode primary spontaneous pneumothorax. Am J Respir Crit care Med 2002;165(9):1240-4. 21. Chan SSW, Timothy HR. Primary spontaneous pneumothorax: 1 year recurrence rate after simple aspiration. European Journal of Emergency Medicine 2006;13(2):88-91. 22. Devanand A, Koh MS, Ong TH, Low SY, Tan KL, et al. Simple aspiration versus chest tube insertion in the management of primary spontaneous pneumothorax: a systematic review. Respir Med 2004;98(7):579-90. 23. Harvey J, Prescott RJ. Simple aspiration versus intercostaltube drainage for spontaneous
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pneumothorax in patients with healthy lungs. Br Med J 1994;309:1338-9. 24. Zehtabchi S, Rios CL. Management of emergency department patients with primary spontaneous pneumothorax: needle aspiration or tube thoracostomy. Annals of Emergency Medicine 2008;51(1):91-100. 25. Rawlins R, Brown KM, Carr CS, Cameron CR. Life threatening haemorrhage after anterior needle aspiration of pneumothoraces. A role for lateral needle aspiration in emergency decompression of spontaneous pneumothorax. Emerg Med J 2003;20:383-4. 26. Kelly AM. Spontaneous pneumothorax: are we treating the X-ray or the patient? Hong Kong J. emerg. Med 2015;22(3):135-6. 27. Hoi K, Turchin B, Kelly AM. How accurate is the light index for estimating pneumothorax size? Austral Radiol 2007;51(12):196-8.
ACCEPTED MANUSCRIPT Table 1
Characteristics and predictors for successful needle aspiration for primary
spontaneous pneumothorax All
Successful
Failed
(n=127)
aspiration
aspiration
(n=73)
(n=54)
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Parameters
24.9 ± 10.3
23.5 ± 8.3
Male gender
114 (89.5%)
67 (91.8%)
47 (87%)
0.394
Active smoker
42 (53.1%)
23 (31.5%)
19 (35.2%)
0.663
70 (55.1%)
41 (56.2%)
29 (53.7%)
57 (44.9%)
32 (43.8%)
25 (46.3%)
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Age, mean ± SD
Right
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Previous pneumothorax
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Side of pneumothorax Left
26.7 ± 12.3
p value
0.219
0.783
25 (19.7%)
12 (16.4%)
13 (24.1%)
0.285
12 (9.4%)
2 (2.7%)
10 (18.5%)
0.004 #
33 (26%)
13 (17.8%)
20 (37%)
0.015
24 ± 43
24 ± 41.5
24 ± 25.6
0.626 *
34 (26.8%)
18 (24.7%)
16 (29.6%)
0.532
55 (43.3%)
32 (43.8%)
23 (42.6%)
0.889
90 (70.9%)
50 (68.5%)
40 (74.1%)
0.494
127 ± 18
128 ± 17
127 ± 18
0.683
73 ± 14
74 ± 13
72 ± 14
0.757
92 ± 63
87 ± 18
100 ± 94
0.644
99 ± 1.2
99 ± 1.2
98 ± 1.2
0.231
19 ± 3
18 ± 3
19 ± 2.8
0.272
43 ± 27
41 ± 24
50.5 ± 36.8
0.006 *
11 ± 16
9 ± 13.5
15.5 ± 17.0
0.003 *
Apex to cupola distance ≥ 50 mm
52 (40.9%)
23 (31.5%)
29 (53.7%)
0.012
Interpleural distance ≥ 30 mm
17 (13.4%)
7 (9.6%)
10 (18.5%)
0.144
Hydropneumothorax in initial chest X-ray
26 (20.5%)
8 (11%)
18 (33.3%)
0.003 #
Signs of mediastinal compression
8 (6.3%)
2 (2.7%)
6 (11.1%)
0.071 #
780 ± 740
690 ± 558
1015 ± 930
0.002 *
Aspirated volume ≥ 1000 ml
43 (33.9%)
16 (31.9%)
27 (50%)
0.001
Aspirated volume ≥ 2500 ml
17 (13.4%)
3 (4.1%)
14 (25.9%)
< 0.001 #
In same side In opposite side Any side Interval from symptom onset to aspirate Median ± IQR, hours
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Within 6 hours Within 12 hours
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Within 24 hours Presenting vital signs (mean ± SD)
Systolic blood pressure, mmHg
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Diastolic blood pressure, mmHg Heart rate, beats per minute
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SpO2 on room air, %
Respiratory rate, breaths per minute Size of pneumothorax (median ± IQR) Apex to cupola distance, mm Interpleural distance at hilum, in mm
(near-complete pulmonary collapse in X-ray + heart rate drop ≥ 20 /min after decompression) Aspirated volume Median ± IQR, in ml
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Length of stay, median± IQR, in days Failure of needle aspiration
1±0
3±7
--
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13 (10.2%)
Immediate failure
41 (32.3%)
Delayed failure
# fisher’s exact test
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* independent sample median test
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ACCEPTED MANUSCRIPT Table 2 Logistic regression predicting failure of needle aspiration Adjusted odds ratio (95% CI)
p value
Hydropneumothorax on presentation Signs of mediastinal compression Large pneumothorax (apex to cupola distance ≥ 5cm) Previous pneumothorax
4.47 (1.56 - 12.83)
0.005
1.2 (0.19 - 7.57) 2.75 (1.21 - 6.26)
0.846 0.016
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Predictors
0.003
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3.92 (1.57 - 9.79)
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Patient presented with hydropneumothorax
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Figure 1
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Outcome of patients with PSP received needle aspiration as primary treatment
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Figure 2