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It Takes a System to Treat a Pneumothorax
EMERGENCY MEDICAL SERVICES/EDITORIAL
It Takes a System to Treat a Pneumothorax James Feldman, MD, MPH 0196-0644/$-see front matter Copyright © 2014 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2014.01.008
SEE RELATED ARTICLE, P.
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[Ann Emerg Med. 2014;--:---.] The optimal treatment of spontaneous pneumothorax remains problematic, with much variation in therapeutic approaches and guideline recommendations. A recent systematic review of the ambulatory treatment of spontaneous pneumothorax noted that high-quality, prospective, randomized, controlled trials have not demonstrated the superiority of any one of the available strategies, especially for patients who have large primary spontaneous pneumothorax (defined as without clinically apparent lung disease or trauma) or secondary spontaneous pneumothorax (pneumothorax occurring with underlying lung disease).1 The British Thoracic guidelines (2010) recommend needle aspiration as the initial intervention despite reported success rates in the range of 30% to 80% and specify that patients with secondary spontaneous pneumothorax should be admitted to the hospital for 24 hours.2 From a patient-centered perspective, one would desire a treatment strategy that maximizes the likelihood of both shortand long-term success and minimizes pain, complications, hospitalization, and costs. Several small studies have suggested that ambulatory treatment with a small-bore catheter (8 Fr) and Heimlich valve, with a short-term success rate of approximately 80%, is an effective strategy.3-6 In a critical review of the literature comparing needle aspiration with tube thoracostomy, Zehtabchi and Rios4 concluded that needle aspiration was associated with similar failure and recurrence rates, but less discomfort and pain and fewer hospitalizations. Early and more aggressive treatment might be a reasonable strategy, however, in patients in whom validated predictors of recurrence could be identified.7,8 In this issue of Annals, Voisin et al9 describe their 4-year experience at a single center in Lorient, France, with a protocol for patients with large primary spontaneous pneumothorax or secondary spontaneous pneumothorax. The protocol included placement of an 8.5-Fr catheter with Heimlich valve, a brief period of observation in the emergency department (ED) (up to 2 hours), and outpatient evaluation by a pulmonologist every 2 days thereafter. Short-term success was defined as complete or near-complete lung re-expansion on chest radiograph before removal on follow-up (day 2 or 4); long-term success was defined as the absence of recurrence at 1 year, as per self-report on a telephone interview. The novelty of the algorithm includes the brief duration of ED observation, omission of aspiration of pneumothorax at catheter insertion, and the inclusion of patients with secondary causes. In the absence of definitive data to guide
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treatment decisions, this study is an important contribution to the existing literature on this topic. The short-term success rate was 83% (95% confidence interval 77% to 89%). This included patients discharged per protocol, as well as those observed in the hospital. Ten patients (7.6%) ultimately required pleurodesis. The 1-year recurrence rate was 26% but could have been as high as 33% if all patients lost to follow-up were assumed to have had recurrences. There were only 2 minor complications associated with the catheters (kinking). The authors noted that this 1-year recurrence rate is consistent with rates reported in the literature (11% to 24% at follow-up periods of between 6 and 31 months).1 How can this center’s experience inform the approach to spontaneous pneumothorax? The Lorient experience supports the use of a pigtail catheter and Heimlich valve on an outpatient basis as an additional therapeutic option in appropriately selected patients when resources are available for close follow-up. One important feature was the implementation of an interdisciplinary approach with coordination between ED treatment and specialty follow-up. The study has a number of important limitations, however. There were only 22 patients with secondary spontaneous pneumothorax, so the recommendation to use this approach in patients with such a pneumothorax must be considered preliminary until a much larger sample size has demonstrated the safety and efficacy of the treatment algorithm. Moreover, rapid discharge of patients with intrinsic lung disease (eg, Chronic Obstructive Pulmonary Disease, emphysema, pneumonia, cancer) would not be desirable when other management options were available, including a longer period of monitoring in an ED observation unit.10 Finally, although reducing unnecessary hospitalizations is an important goal, it is not clear that this approach is appropriate or would be applicable in a system in which there is a lower tolerance for adverse outcomes. Nevertheless, the Lorient management strategy appears to be superior to mandatory tube thoracostomy with its associated complications,11 and need for hospital admission, in patients with large spontaneous pneumothorax. As outpatient management of various clinical conditions continues to be explored, the organization of systems to help achieve this goal for large spontaneous pneumothorax will become increasingly important. The authors noted that these results need to be confirmed in a large multicenter trial of treatments for large spontaneous pneumothorax. Determination of the optimal treatment strategy for spontaneous pneumothorax would be an appropriate subject for a high-quality observational registry and a registry-based randomized clinical trial.12
Annals of Emergency Medicine 1
Feldman
Treating Pneumothorax
Supervising editor: Allan B. Wolfson, MD Author affiliations: From the Department of Emergency Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA. Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The author has stated that no such relationships exist.
5.
6. 7.
8.
Address for correspondence: James Feldman, MD, MPH, E-mail [email protected]. REFERENCES 1. Brims FJ, Maskell NA. Ambulatory treatment in the management of pneumothorax: a systematic review of the literature. Thorax. 2013;68:664-669. 2. MacDuff A, Arnold A, Harvey J, et al. Management of spontaneous pneumothorax: Brtish Thoracic Society pleural disease guideline 2010. Thorax. 2010;65(suppl 2):ii18-ii31. 3. Devanand A, Koh MS, Ong TH, et al. Simple aspiration versus chest-tube insertion in the management of primary spontaneous pneumothorax: a systematic review. Respir Med. 2004;98:579-590. 4. Zehtabchi S, Rios CL. Management of emergency department patients with primary spontaneous pneumothorax: needle
2 Annals of Emergency Medicine
9.
10.
11.
12.
aspiration or tube thoracostomy? Ann Emerg Med. 2008;51:91-100, 100.e1. Ho KK, Ong ME, Koh MS, et al. A randomized controlled trial comparing minichest tube and needle aspiration in outpatient management of primary spontaneous pneumothorax. Am J Emerg Med. 2011;29:1152-1157. Kelly AM. Treatment of primary spontaneous pneumothorax. Curr Opin Pulm Med. 2009;15:376-379. Ganesalingam R, O’Neil RA, Shadbolt B, et al. Radiological predictors of recurrent primary spontaneous pneumothorax following non-surgical management. Heart Lung Circ. 2010;19:606-610. Chambers A, Scarci M. In patients with first-episode primary spontaneous pneumothorax is video-assisted thoracoscopic surgery superior to tube thoracostomy alone in terms of time to resolution of pneumothorax and incidence of recurrence? Interact Cardiovasc Thorac Surg. 2009;9:1003-1008. Voisin F, Sohier L, Rochas Y, et al. Ambulatory Management of Large Spontaneous Pneumothorax With Pigtail Catheters. Ann Emerg Med. 2014; http://dx.doi.org/10.1016/j.annemergmed. 2013.12.017. Kuan WS, Lather KS, Mahadevan M. Primary spontaneous pneumothorax—the role of the emergency observation unit. Am J Emerg Med. 2011;29:293-298. Sethuraman KN, Duong D, Mehta S, et al. Complications of tube thoracostomy placement in the emergency department. J Emerg Med. 2011;40:14-20. Lauer MS, D’Agostino RB. The randomized registry trial—the next disruptive technology in clinical research? N Engl J Med. 2013;369:1579-1581.
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It Takes a System to Treat a Pneumothorax James Feldman, MD, MPH 0196-0644/$-see front matter Copyright © 2014 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2014.01.008
SEE RELATED ARTICLE, P.
.
---
[Ann Emerg Med. 2014;--:---.] The optimal treatment of spontaneous pneumothorax remains problematic, with much variation in therapeutic approaches and guideline recommendations. A recent systematic review of the ambulatory treatment of spontaneous pneumothorax noted that high-quality, prospective, randomized, controlled trials have not demonstrated the superiority of any one of the available strategies, especially for patients who have large primary spontaneous pneumothorax (defined as without clinically apparent lung disease or trauma) or secondary spontaneous pneumothorax (pneumothorax occurring with underlying lung disease).1 The British Thoracic guidelines (2010) recommend needle aspiration as the initial intervention despite reported success rates in the range of 30% to 80% and specify that patients with secondary spontaneous pneumothorax should be admitted to the hospital for 24 hours.2 From a patient-centered perspective, one would desire a treatment strategy that maximizes the likelihood of both shortand long-term success and minimizes pain, complications, hospitalization, and costs. Several small studies have suggested that ambulatory treatment with a small-bore catheter (8 Fr) and Heimlich valve, with a short-term success rate of approximately 80%, is an effective strategy.3-6 In a critical review of the literature comparing needle aspiration with tube thoracostomy, Zehtabchi and Rios4 concluded that needle aspiration was associated with similar failure and recurrence rates, but less discomfort and pain and fewer hospitalizations. Early and more aggressive treatment might be a reasonable strategy, however, in patients in whom validated predictors of recurrence could be identified.7,8 In this issue of Annals, Voisin et al9 describe their 4-year experience at a single center in Lorient, France, with a protocol for patients with large primary spontaneous pneumothorax or secondary spontaneous pneumothorax. The protocol included placement of an 8.5-Fr catheter with Heimlich valve, a brief period of observation in the emergency department (ED) (up to 2 hours), and outpatient evaluation by a pulmonologist every 2 days thereafter. Short-term success was defined as complete or near-complete lung re-expansion on chest radiograph before removal on follow-up (day 2 or 4); long-term success was defined as the absence of recurrence at 1 year, as per self-report on a telephone interview. The novelty of the algorithm includes the brief duration of ED observation, omission of aspiration of pneumothorax at catheter insertion, and the inclusion of patients with secondary causes. In the absence of definitive data to guide
Volume
-,
no.
-
:
-
2014
treatment decisions, this study is an important contribution to the existing literature on this topic. The short-term success rate was 83% (95% confidence interval 77% to 89%). This included patients discharged per protocol, as well as those observed in the hospital. Ten patients (7.6%) ultimately required pleurodesis. The 1-year recurrence rate was 26% but could have been as high as 33% if all patients lost to follow-up were assumed to have had recurrences. There were only 2 minor complications associated with the catheters (kinking). The authors noted that this 1-year recurrence rate is consistent with rates reported in the literature (11% to 24% at follow-up periods of between 6 and 31 months).1 How can this center’s experience inform the approach to spontaneous pneumothorax? The Lorient experience supports the use of a pigtail catheter and Heimlich valve on an outpatient basis as an additional therapeutic option in appropriately selected patients when resources are available for close follow-up. One important feature was the implementation of an interdisciplinary approach with coordination between ED treatment and specialty follow-up. The study has a number of important limitations, however. There were only 22 patients with secondary spontaneous pneumothorax, so the recommendation to use this approach in patients with such a pneumothorax must be considered preliminary until a much larger sample size has demonstrated the safety and efficacy of the treatment algorithm. Moreover, rapid discharge of patients with intrinsic lung disease (eg, Chronic Obstructive Pulmonary Disease, emphysema, pneumonia, cancer) would not be desirable when other management options were available, including a longer period of monitoring in an ED observation unit.10 Finally, although reducing unnecessary hospitalizations is an important goal, it is not clear that this approach is appropriate or would be applicable in a system in which there is a lower tolerance for adverse outcomes. Nevertheless, the Lorient management strategy appears to be superior to mandatory tube thoracostomy with its associated complications,11 and need for hospital admission, in patients with large spontaneous pneumothorax. As outpatient management of various clinical conditions continues to be explored, the organization of systems to help achieve this goal for large spontaneous pneumothorax will become increasingly important. The authors noted that these results need to be confirmed in a large multicenter trial of treatments for large spontaneous pneumothorax. Determination of the optimal treatment strategy for spontaneous pneumothorax would be an appropriate subject for a high-quality observational registry and a registry-based randomized clinical trial.12
Annals of Emergency Medicine 1
Feldman
Treating Pneumothorax
Supervising editor: Allan B. Wolfson, MD Author affiliations: From the Department of Emergency Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA. Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The author has stated that no such relationships exist.
5.
6. 7.
8.
Address for correspondence: James Feldman, MD, MPH, E-mail [email protected]. REFERENCES 1. Brims FJ, Maskell NA. Ambulatory treatment in the management of pneumothorax: a systematic review of the literature. Thorax. 2013;68:664-669. 2. MacDuff A, Arnold A, Harvey J, et al. Management of spontaneous pneumothorax: Brtish Thoracic Society pleural disease guideline 2010. Thorax. 2010;65(suppl 2):ii18-ii31. 3. Devanand A, Koh MS, Ong TH, et al. Simple aspiration versus chest-tube insertion in the management of primary spontaneous pneumothorax: a systematic review. Respir Med. 2004;98:579-590. 4. Zehtabchi S, Rios CL. Management of emergency department patients with primary spontaneous pneumothorax: needle
2 Annals of Emergency Medicine
9.
10.
11.
12.
aspiration or tube thoracostomy? Ann Emerg Med. 2008;51:91-100, 100.e1. Ho KK, Ong ME, Koh MS, et al. A randomized controlled trial comparing minichest tube and needle aspiration in outpatient management of primary spontaneous pneumothorax. Am J Emerg Med. 2011;29:1152-1157. Kelly AM. Treatment of primary spontaneous pneumothorax. Curr Opin Pulm Med. 2009;15:376-379. Ganesalingam R, O’Neil RA, Shadbolt B, et al. Radiological predictors of recurrent primary spontaneous pneumothorax following non-surgical management. Heart Lung Circ. 2010;19:606-610. Chambers A, Scarci M. In patients with first-episode primary spontaneous pneumothorax is video-assisted thoracoscopic surgery superior to tube thoracostomy alone in terms of time to resolution of pneumothorax and incidence of recurrence? Interact Cardiovasc Thorac Surg. 2009;9:1003-1008. Voisin F, Sohier L, Rochas Y, et al. Ambulatory Management of Large Spontaneous Pneumothorax With Pigtail Catheters. Ann Emerg Med. 2014; http://dx.doi.org/10.1016/j.annemergmed. 2013.12.017. Kuan WS, Lather KS, Mahadevan M. Primary spontaneous pneumothorax—the role of the emergency observation unit. Am J Emerg Med. 2011;29:293-298. Sethuraman KN, Duong D, Mehta S, et al. Complications of tube thoracostomy placement in the emergency department. J Emerg Med. 2011;40:14-20. Lauer MS, D’Agostino RB. The randomized registry trial—the next disruptive technology in clinical research? N Engl J Med. 2013;369:1579-1581.
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