Simplified stepwise management of primary spontaneous pneumothorax: a pilot study

Abstract

In primary spontaneous pneumothorax (PSP) requiring intervention, removal of air from the pleural space can be achieved by manual needle aspiration or by pleural drainage after insertion of a chest tube. This study aimed to evaluate the efficacy and safety of a serial-steps approach with a single system (small-calibre catheter/Heimlich valve) in a homogeneous population of patients with a first episode of PSP.All patients had an 8.5 F distally multiperforated polyurethane pigtail catheter inserted via the anterior route, at the bedside without any guidance, using the Seldinger technique. A one-way Heimlich valve was connected to the catheter, allowing the air to flow spontaneously outwards for 24-48 h. Thereafter, if the lung failed to re-expand wall suction was applied. Patients with an air leak persisting for .4 days were referred for surgery. Primary end-points were success rates at 24 h and 1 week, and 1 yr recurrence-free survival.In total, 41 consecutive patients entered the study. They were typically thin, young, smoking males. No procedure-related complications were observed. The need for pain relief medication was minimal. Within the first 24 h, most of the patients were able to walk around and half of them were able to take a shower with their catheter in place. The 24-h and 1-week success rates were 61 and 85%, respectively, and the actuarial 1-yr recurrence rate was 24%. Four patients underwent surgical pleurodesis because of a persistent air leak. The length of stay when excluding the four surgical cases was 2.3¡1.3 days.When 24-h and 1-week success rates and recurrence at 12 months were taken as end-points, the method described here is as effective as simple manual needle aspiration or a conventional chest tube thoracotomy. These results support further studies assessing this ''one system, serialsteps approach'' in an outpatient management algorithm.

Simple sequential treatment for primary spontaneous pneumothorax: one step closer

“…Thereafter, those who have an obvious persistent air leak on underwater seal or failure of full re-expansion could have the system replaced by the Heimlich valve. As MARQUETTE et al [9] have shown, these patients remain mobile and comfortable with this system. They could be allowed home from the emergency department to return after a further 24-48 h for further chest radiography and clinical assessment, followed either by removal of the catheter or admission for negative pressure suction or surgical intervention if air leak persists beyond 4 days.…”

“…In conclusion, the pilot study presented by MARQUETTE et al [9] in this issue of the European Respiratory Journal brings us one step closer to developing a universally accepted, predominantly outpatient-based protocol for the management of primary spontaneous pneumothorax. While treatment strategies will always have to be tailored to the individual patient, emerging evidence, including that provided here, should encourage us to develop further trials to facilitate the creation of a simple sequential algorithmic approach to the general management patients with primary spontaneous pneumothorax [9,14].…”

“…Both definitions are unwieldy and as the lung does not often deflate in a uniform manner around the whole circumference, all such equations are unreliable. In the current issue of the European Respiratory Journal, MARQUETTE et al [9] provide a simplified approach to the management of PSP. It is interesting that the authors note that in their population of 41 consecutive PSP patients, 98% would be defined as large pneumothoraces using ACCP criteria but only 68% would be defined as such according to BTS criteria, suggesting that fewer patients would be treated invasively using BTS criteria for PSP assessment.…”

“…Negative pressure suction may be added to the system in those who do not achieve full re-expansion of the lungs after 24 h, as demonstrated by VALLEE et al [19] as early as 1988. In their pilot study, MARQUETTE et al [9] demonstrate a single aspiration system that facilitates a simplified sequential steps approach to the treatment of these patients using an 8.5F catheter attached to a Heimlich one-way valve rather than an underwater seal system. The catheters were inserted using the Seldinger technique in 41 consecutive PSP patients.…”

Ambulatory management of primary spontaneous pneumothorax: the good is (not always) the enemy of the better (evidence)

“…In a report published previously in the European Respiratory Journal (ERJ), MARQUETTE et al [7] showed that a small-calibre catheter attached to a Heimlich valve could be safely proposed as the treatment of choice in hospitalised patients with a large PSP and potentially replace secondary (large-bore) chest tube insertion in those who fail simple manual needle aspiration. The use of a Heimlich valve may offer several advantages when compared with an underwater seal bottle system.…”