Large primary spontaneous pneumothorax (PSP) has traditionally been managed with needle aspiration, chest tube drainage and, in refractory cases, thoracic surgery. A recent randomized trial, however, provided evidence that a conservative observational approach was safe and 85% of patients recovered without requiring pleural drainage interventions. A conservative approach provided similar re‐expansion rates at 8 weeks compared with chest tube drainage and offered the advantages of early hospital discharge, fewer days off work and avoidance of procedural risks. Nonetheless, clinicians are understandably anxious with conservative (non‐drainage) management for patients with very large pneumothorax. Here, we report a patient with a right‐sided PSP and total lung collapse that was managed successfully without intervention with minimal time in hospital or off work.
Indwelling pleural catheter is an established management for malignant pleural effusions. Extending its use to patients with malignant ascites by insertion of a catheter intraperitoneally enables regular outpatient drainage and improves quality‐of‐life. However, indwelling pleural/peritoneal catheter (IPC/IPeC) is associated with catheter‐related infections, traditionally managed with systemic antibiotics and occasionally requires catheter removal. Direct administration of antibiotics intra‐abdominally via peritoneal dialysis (PD) catheters is a well‐established, efficacious practice in PD‐related peritonitis and minimizes systemic adverse effects. We applied the same principles to a patient with peritoneal mesothelioma who developed peritonitis 3 weeks after insertion of IPeC. Intraperitoneal vancomycin was administered via, and compatible with, the IPeC. The patient tolerated the treatment without adverse effects and made a full recovery without requiring catheter removal.
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