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Simple aspiration of spontaneous pneumothorax
BY. J. Dis. Chest (1981) 75, 207
SIMPLE ASPIRATION OF SPONTANEOUS PNEUMOTHORAX 0. G. RAJA* AND A. J. LALOR Harrogate
District
Hospital;
Odstock Hospital,
Salisbury
A simple method of treating spontaneous pneumothorax by direct aspiration is described. For patients in whom this method was considered suitable the average stay in hospital was only three days and the discomfort and inconvenience of an intercostal tube were avoided. Method A site in the second intercostal space and mid-clavicular line is infiltrated with local anaesthetic. A 50 ml disposable plastic syringe is attached to a three-way tap, to the side arm of which is attached 45 cm length of delivery tube from an intravenous administration set. The patient is instructed to hold his breath in expiration. A Medicut 18G intravenous cannula, to which a syringe is attached, is inserted through the chest wall. Suction is exerted as the cannula is advanced and at the point where air rushes into the syringe the cannula is advanced over the needle and the needle and syringe are withdrawn simultaneously. The three-way tap connected to the 50 ml syringe and the side delivery tube is now attached to the cannula. Air is now removed as in aspirating a pleural emphysema, care being taken to exert only gentle suction. We have found it useful to immerse the end of the delivery tube in a bowl of sterile water, so that a rising water level in the delivery tube acts as a warning that the stopcock tap is incorrectly positioned. As the lung expands it comes to lie against the tip of the cannula, preventing further aspiration of air. More air can then be removed, either by lying the patient flat or by withdrawing the cannula slightly. Throughout the procedure care should be taken to hold the flexible plastic cannula steady to avoid kinking and movement of the tip. The chest radiograph is repeated after four hours. If the pneumothorax is larger insertion of an intercostal tube and closed drainage are required. If the pneumothorax is the same size or slightly smaller, the procedure may be repeated. PILOT STUDY
In a small pilot study we have used this method in treating patients with moderate pneumothoraces of less than 50% and those with larger but relatively symptomless pneumothoraces. Patients who were very breathless, emphysematous or elderly were treated conventionally with intercostal tube drainage. Of 33 consecutive patients who presented with pnuemothorax, 13 were treated by this method, four were treated conservatively and the remainder were treated with intercostal drainage. Of the 13 patients on whom this method was used, three had a history of previous pneumothoraces which had been treated conventionally. All 13 were aspirated soon * Present
address : William
Harvey
Hospital,
Ashford,
Kent.
208
0. G. Raja and A. J. Lalor
after admission. One patient required a second aspiration on the next day and, as the pneumothorax occurred again, a chest drain was inserted on the third day. One patient required three aspirations over two days and was discharged home on the third day, to be readmitted a week later with a recurrence which required a chest drain. Follow-up of the nine patients successfully treated by this method showed no recurrence of the pneumothorax within six months. The average length of stay in hospital was three days. DISCUSSION
Stradling and Poole (1966) successfully managed more than 80% of the patients presenting to the Hammersmith Chest Clinic between 19.54 and 1961 with conservative treatment. The average length of hospital stay in several series of patients treated by intercostal tube varied from five to 30 days with a mean of 13 days (Klassen & Meckstroth 1962; Smith & Rothwell 1962; Killen & Jackson 1963; Ransdell & McPherson 1963; Withers et al. 1964; Lynn 1965; Timmis et al. 1965; Thompson & Bailey 1966). Single and multiple needle aspirations were used by Klassen and Meckstroth (1962) as primary treatment in three patients, with good results in two. The third patient, however, required an intercostal tube drain because of the failure of the lung to expand and because of the appearance of an area of haemorrhage in the lung at a point opposite the location of the aspirating needle. We suggest that the substitution of an intravenous cannula for a needle reduces the risk of damage to the lung and that simple aspiration not only avoids the discomfort and inconvenience of the insertion of an intercostal tube but also shortens the hospital stay of patients with uncomplicated pneumothoraces. ACKNOWLEDGEMENTS
We would like to thank Dr S. J. Cameron for advice during the study and help in the preparation of the paper and Dr W. S. Suffern and Dr A. G. Stewart for allowing us to treat their patients. REFERENCES KILLEN, D. A. & JACKSON, L. M. (1963) Management of spontaneous pneumothorax. r. Tennessee med. Ass. 56, 439. KLASSEN, K. P. & MECKSTROTH, C. V. (1962) Treatment of spontaneous pneumothorax. y. Am. med. Ass. 182, 1. LYNN, R. B. (1965) Spontaneous pneumothorax. Dis. Chest 48, 251. RANSDELL, H. T. & MCPHERSON, R. C. (1963) Management of spontaneous pneumothorax: a comparison of treatment methods. Archs Surg., Chicago 87, 1023. SMITH, W. G. & ROTHWELL, P. P. G. (1962) Treatment of spontaneous pneumothorax. Thorax 17, 342. STRADLING, P. & POOLE, G. (1966) Conservative management of spontaneous pneumothorax. Thorax 21, 145. THOMPSON, H. T. & BAILEY, R. R. (1966) Management of spontaneous pneumothorax. N.Z. med. J. 65, 101. TIMMIS, H. T., VIRGILIO, R. & MCCLENATHAN, J. E. (1965) Spontaneous pneumothorax. Am. J. Surg. 110, 929. WITHERS, J. N., FISHBACK, M. E., KIEHL, P. V. & HANNON, J. L. (1964) Spontaneous pneumothorax: suggested aetiology and comparison of treatment methods. Am. J. Surg. 108, 772.
SIMPLE ASPIRATION OF SPONTANEOUS PNEUMOTHORAX 0. G. RAJA* AND A. J. LALOR Harrogate
District
Hospital;
Odstock Hospital,
Salisbury
A simple method of treating spontaneous pneumothorax by direct aspiration is described. For patients in whom this method was considered suitable the average stay in hospital was only three days and the discomfort and inconvenience of an intercostal tube were avoided. Method A site in the second intercostal space and mid-clavicular line is infiltrated with local anaesthetic. A 50 ml disposable plastic syringe is attached to a three-way tap, to the side arm of which is attached 45 cm length of delivery tube from an intravenous administration set. The patient is instructed to hold his breath in expiration. A Medicut 18G intravenous cannula, to which a syringe is attached, is inserted through the chest wall. Suction is exerted as the cannula is advanced and at the point where air rushes into the syringe the cannula is advanced over the needle and the needle and syringe are withdrawn simultaneously. The three-way tap connected to the 50 ml syringe and the side delivery tube is now attached to the cannula. Air is now removed as in aspirating a pleural emphysema, care being taken to exert only gentle suction. We have found it useful to immerse the end of the delivery tube in a bowl of sterile water, so that a rising water level in the delivery tube acts as a warning that the stopcock tap is incorrectly positioned. As the lung expands it comes to lie against the tip of the cannula, preventing further aspiration of air. More air can then be removed, either by lying the patient flat or by withdrawing the cannula slightly. Throughout the procedure care should be taken to hold the flexible plastic cannula steady to avoid kinking and movement of the tip. The chest radiograph is repeated after four hours. If the pneumothorax is larger insertion of an intercostal tube and closed drainage are required. If the pneumothorax is the same size or slightly smaller, the procedure may be repeated. PILOT STUDY
In a small pilot study we have used this method in treating patients with moderate pneumothoraces of less than 50% and those with larger but relatively symptomless pneumothoraces. Patients who were very breathless, emphysematous or elderly were treated conventionally with intercostal tube drainage. Of 33 consecutive patients who presented with pnuemothorax, 13 were treated by this method, four were treated conservatively and the remainder were treated with intercostal drainage. Of the 13 patients on whom this method was used, three had a history of previous pneumothoraces which had been treated conventionally. All 13 were aspirated soon * Present
address : William
Harvey
Hospital,
Ashford,
Kent.
208
0. G. Raja and A. J. Lalor
after admission. One patient required a second aspiration on the next day and, as the pneumothorax occurred again, a chest drain was inserted on the third day. One patient required three aspirations over two days and was discharged home on the third day, to be readmitted a week later with a recurrence which required a chest drain. Follow-up of the nine patients successfully treated by this method showed no recurrence of the pneumothorax within six months. The average length of stay in hospital was three days. DISCUSSION
Stradling and Poole (1966) successfully managed more than 80% of the patients presenting to the Hammersmith Chest Clinic between 19.54 and 1961 with conservative treatment. The average length of hospital stay in several series of patients treated by intercostal tube varied from five to 30 days with a mean of 13 days (Klassen & Meckstroth 1962; Smith & Rothwell 1962; Killen & Jackson 1963; Ransdell & McPherson 1963; Withers et al. 1964; Lynn 1965; Timmis et al. 1965; Thompson & Bailey 1966). Single and multiple needle aspirations were used by Klassen and Meckstroth (1962) as primary treatment in three patients, with good results in two. The third patient, however, required an intercostal tube drain because of the failure of the lung to expand and because of the appearance of an area of haemorrhage in the lung at a point opposite the location of the aspirating needle. We suggest that the substitution of an intravenous cannula for a needle reduces the risk of damage to the lung and that simple aspiration not only avoids the discomfort and inconvenience of the insertion of an intercostal tube but also shortens the hospital stay of patients with uncomplicated pneumothoraces. ACKNOWLEDGEMENTS
We would like to thank Dr S. J. Cameron for advice during the study and help in the preparation of the paper and Dr W. S. Suffern and Dr A. G. Stewart for allowing us to treat their patients. REFERENCES KILLEN, D. A. & JACKSON, L. M. (1963) Management of spontaneous pneumothorax. r. Tennessee med. Ass. 56, 439. KLASSEN, K. P. & MECKSTROTH, C. V. (1962) Treatment of spontaneous pneumothorax. y. Am. med. Ass. 182, 1. LYNN, R. B. (1965) Spontaneous pneumothorax. Dis. Chest 48, 251. RANSDELL, H. T. & MCPHERSON, R. C. (1963) Management of spontaneous pneumothorax: a comparison of treatment methods. Archs Surg., Chicago 87, 1023. SMITH, W. G. & ROTHWELL, P. P. G. (1962) Treatment of spontaneous pneumothorax. Thorax 17, 342. STRADLING, P. & POOLE, G. (1966) Conservative management of spontaneous pneumothorax. Thorax 21, 145. THOMPSON, H. T. & BAILEY, R. R. (1966) Management of spontaneous pneumothorax. N.Z. med. J. 65, 101. TIMMIS, H. T., VIRGILIO, R. & MCCLENATHAN, J. E. (1965) Spontaneous pneumothorax. Am. J. Surg. 110, 929. WITHERS, J. N., FISHBACK, M. E., KIEHL, P. V. & HANNON, J. L. (1964) Spontaneous pneumothorax: suggested aetiology and comparison of treatment methods. Am. J. Surg. 108, 772.