Original Thoracic

Outcomes of Outpatient Treatment for Primary Spontaneous Pneumothorax Using a Small-Bore Portable Thoracic Drainage Device Takahiro Karasaki1,3 Yukihiro Yoshida3

Shizuya Shintomi2

Yukihiro Nomura3

1 Department of Thoracic Surgery, The University of Tokyo Hospital,

Tokyo, Japan 2 Department of Cardiovascular Surgery, Tokyo Women’s Medical University, Tokyo, Japan 3 Department of Surgery, Asahi General Hospital, Asahi, Japan 4 Department of Respiratory Medicine, Asahi General Hospital, Asahi, Japan

Nobutaka Tanaka3

Haruhisa Saito4

Address for correspondence Yukihiro Yoshida, MD, Department of Surgery, Asahi General Hospital, I-1326, Asahi, Chiba 289-2511, Japan (e-mail: [email protected]).

Thorac Cardiovasc Surg 2014;62:516–520.

Abstract

Keywords

► pneumothorax ► quality of life ► outcomes

Background There is no consensus regarding the initial intervention for primary spontaneous pneumothorax. We report the outcomes of outpatient treatment for primary spontaneous pneumothorax using a portable thoracic drainage device. Patients and Methods Between April 2007 and December 2011, 99 consecutive patients with a first episode of primary spontaneous pneumothorax were indicated for insertion of a portable thoracic drainage device. All patients were treated with a smallbore portable thoracic drainage device that consists of a flexible 9F silicone catheter with one-way valves and a small plastic chamber. Successful treatment was defined as when the pneumothorax was resolved after the insertion of a portable thoracic drainage device solely on an outpatient basis. Demographic data and treatment outcomes were obtained by a retrospective chart review. Results Ninety-seven patients (98%) with a first primary spontaneous pneumothorax were discharged from the emergency department after insertion of a portable thoracic drainage device. Ninety-three patients (94%) resolved with outpatient treatment. The median duration of portable thoracic drainage device insertion was 4 days (range, 0–33 days). The recurrence rate after treatment with a portable thoracic drainage device was 34% (32/93). There were two infections (2.0%), two instances of hemothoraces (2.0%), and one severe discomfort at the insertion site (1.0%). There were no cases of tension pneumothorax or reexpansion edema. Conclusion Outpatient treatment for primary spontaneous pneumothorax using a portable thoracic drainage device had a high success rate with few serious complications and an acceptable recurrence rate.

Introduction Primary spontaneous pneumothorax is defined as a spontaneously occurring pneumothorax in a patient without

received January 7, 2014 accepted after revision February 27, 2014 published online May 29, 2014

clinically apparent underlying pulmonary disease. Such patients are often young, such as working people or students.1,2 Treatment options for primary spontaneous pneumothorax

© 2014 Georg Thieme Verlag KG Stuttgart · New York

DOI http://dx.doi.org/ 10.1055/s-0034-1374650. ISSN 0171-6425.

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

516

include observation, needle aspiration, chest tube drainage, and surgery. While there are several national guidelines, there is no international consensus.3–5 According to the Consensus Statement by American College of Chest Physicians, clinically stable patients with large pneumothoraces should undergo a procedure to reexpand the lung and should be hospitalized in most instances, while reliable patients who are unwilling to undergo hospitalization may be discharged home from the emergency department with a small-bore catheter attached to a Heimlich valve.3 In the British guidelines, needle aspiration is recommended for symptomatic primary spontaneous pneumothorax, and this is associated with fewer hospital admissions and a shorter hospital stay compared with conventional chest tube drainage.4 However, the success rate for needle aspiration varies from 30 to 80%, which means that several patients will eventually be admitted and undergo chest tube drainage. Outpatient care with small-bore (< 14F) chest drains is thought to have a success rate similar to that with larger drains while being less painful.6 One of the authors developed spontaneous pneumothorax when he was taking the board exam for his medical license. With a small-bore portable drainage device inserted in his chest, he was able to complete the exam for the rest of the 2 days, and eventually became a thoracic surgeon. Outpatient management of spontaneous pneumothorax using a portable thoracic drainage device allows the patient to continue their daily life and to help decide the timing of further treatment, such as additional treatment for prolonged air leak or surgery to reduce the risk of recurrence, and thus may offer an improved quality of life. On the contrary, no randomized controlled trials with an adequate sample size have compared needle aspiration and small-bore catheter drainage, and this may be one of the reasons why small-bore catheter drainage has not yet been recommended as one of the first choices for the management of primary spontaneous pneumothorax. We describe here the outcomes of outpatient management for primary spontaneous pneumothorax in our institution using a small-bore portable thoracic drainage device, which may become one of the first choices in primary spontaneous pneumothorax management.

Karasaki et al.

thorax patients were as follows: (1) hemodynamically stable, (2) minimum amount of pleural effusion, and (3) no underlying lung disease. Tension pneumothorax was not indicated, and iatrogenic or traumatic cases were also not indicated for this treatment. If the distance from the apex to the cupola was less than 3 cm or if the distance between the lung surface and the lateral chest wall was less than 2 cm on chest X-ray, and if the patient did not feel shortness of breath, the pneumothorax was generally only observed. We excluded patients older than 50 years, in this study, based on a consideration of other reports and guidelines on primary spontaneous pneumothorax management.4,7,8 In all patients who were indicated for the insertion of a portable thoracic drainage device, we used a Thoracic Egg (Sumitomo Bakelite Co., Ltd., Tokyo, Japan). A Thoracic Egg consists of a flexible 9F silicone catheter with two one-way valves (Heimlich valves) and a small plastic chamber (►Fig. 1). Under local anesthesia, a 2- to 5-mm skin incision is made after a test puncture in the second or third intercostal space on the middle clavicular line, or in the fourth or fifth intercostal space on the anterior axillary line. The silicone catheter is inserted into the thoracic cavity with a puncture needle, which is then removed. The plastic chamber is connected to the catheter, and the catheter is fixed to the chest wall with suture and adhesive tape. While manual pumping of the bottle facilitates the drainage of air, due to the possibility of reexpansion pulmonary edema, we do not encourage the pumping maneuver. Successful insertion of the catheter was confirmed by chest radiograph obtained after insertion, and patients were discharged from the emergency room if (1) the catheter was placed properly in the thoracic cavity, (2) expansion of the lung had improved, (3) there were no complications such as hemothorax, and if (4) the improvement of symptoms was confirmed while the patient remained in the emergency room for about 1 hour. Discharged patients were followed up in the outpatient clinic within 24 to 72 hours. Thereafter, patients visited the clinic once or twice a week for wound evaluation and to have their dressings changed. Chest radiography was performed at every visit to evaluate the expansion of the lung. The catheter

Patients and Methods This study was conducted in accordance with the amended Declaration of Helsinki. This retrospective study was approved by the Institutional Review Board. In this study, we retrospectively reviewed the records and charts of patients who underwent primary spontaneous pneumothorax treatment with the insertion of a portable thoracic drainage device between April 2007 and December 2011 at Asahi General Hospital, Asahi, Japan. We excluded patients with a previous history of ipsilateral pneumothorax. Contralateral pneumothorax was recorded separately from the cumulative treatment outcomes of ipsilateral pneumothorax. The indications for the insertion of a small-bore portable thoracic drainage device for primary spontaneous pneumo-

Fig. 1 Thoracic Egg (Sumitomo Bakelite Co., Ltd., Tokyo, Japan). A portable thoracic drainage device for pneumothorax, which consists of a flexible 9F silicone catheter with a puncture needle and a small plastic chamber with one-way valves. Thoracic and Cardiovascular Surgeon

Vol. 62

No. 6/2014

517

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

Outpatient Treatment for Primary Spontaneous Pneumothorax

Outpatient Treatment for Primary Spontaneous Pneumothorax was inserted until full expansion of the lung was confirmed by chest radiograph, and until the cessation of air leakage was confirmed by a lack of flutter of the one-way valve of the portable thoracic drainage device. At that time, primary spontaneous pneumothorax was considered to have been successfully resolved, and the catheter was removed. When the pneumothorax was resolved after the insertion of a portable thoracic drainage device on an outpatient basis without the need for admission for further treatment, the case was considered to have been successfully treated. While routine or continuous follow-up is not necessary after primary spontaneous pneumothorax treatment, patients are told to seek medical attention immediately if they feel any symptoms that suggest the recurrence of primary spontaneous pneumothorax. The treatment of patients with recurrent pneumothoraces or prolonged air leaks was discussed by a multidisciplinary team that included general thoracic surgeons. Surgery was recommended for such cases, although repeated or continuous treatment using a portable thoracic drainage device was chosen if patients refused admission and surgery. The surgical procedure was video-assisted thoracoscopic surgery bullectomy with or without staple line coverage with absorbable mesh.9,10

Results A total of 99 consecutive patients were included in this study. The patients’ characteristics are shown in ►Table 1. Ninetyseven patients (98%) successfully underwent insertion of a small-bore pleural catheter and outpatient management was initiated (►Fig. 2). One patient who developed hemothorax was admitted, and surgical treatment was performed the next day. Another patient who had a small amount of sanguineous effusion at the time of catheter insertion was also admitted, but this patient did not require further intervention. During the outpatient management, two patients were suspected to have had infections, but the pneumothorax had already resolved and the catheter was removed. They did not require further intervention except for oral antibiotics. One patient had severe discomfort at the insertion site and Table 1 Characteristics of 99 patients with a first episode of primary spontaneous pneumothorax Variables Total number of patients Age (y)

99

a

22 (13–50)

Sex Male

90 (91%)

Female

9 (9%)

Pneumothorax side Left

55 (56%)

Right

44 (44%)

Duration of catheter insertion (d) a

a

Values represent medians (range).

Thoracic and Cardiovascular Surgeon

Vol. 62

No. 6/2014

4 (0–33)

Karasaki et al.

Fig. 2 Patient flow diagram after the insertion of a portable thoracic drainage device.

the catheter was removed, but the pneumothorax had already resolved. Four patients underwent surgical treatment because of persistent air leakage or deterioration of the pneumothorax. Surgical intervention was generally suggested for patients with persistent air leakage, although five patients who were unwilling to be admitted continued to receive outpatient treatment with a portable thoracic drainage device for more than 2 weeks. The median duration of portable thoracic drainage device insertion was 4 days (range, 0–33 days). There were no cases of tension pneumothorax or reexpansion edema. Ninety-three patients (94%) were eventually treated solely in an outpatient setting. Oral nonsteroidal anti-inflammatory drugs were prescribed at the day of insertion of the catheter and patients were instructed to take drugs in case of pain. Additional prescriptions were not necessary in most cases. One patient underwent elective surgery for the prevention of recurrent pneumothorax after successful treatment by a portable thoracic drainage device. Among the 93 patients who were treated only with a portable thoracic drainage device at the first episode of pneumothorax, 32 (34%) had ipsilateral recurrence of pneumothorax. The median duration between device removal and recurrence was 33 days (range, 2–749 days). Outpatient treatment with a portable thoracic drainage device was initiated in 25 patients with a second episode of primary spontaneous pneumothorax who were unwilling to be admitted or undergo surgery. Among these 25 patients, 23 (92%) resolved with a portable thoracic drainage device alone. Two patients underwent elective surgery after the successful treatment of recurrent pneumothorax with a portable thoracic drainage device. Among the 21 patients who were treated only with a portable thoracic drainage device for both the first and second episodes of pneumothorax, 9 (43%) had three or more episodes of ipsilateral pneumothorax. Among the 99 patients included in the study, a total of 18 patients eventually underwent surgery, including 12 who underwent surgery after one or more episodes of ipsilateral recurrent pneumothoraces. Among the 18 patients who

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

518

underwent surgery, 3 had recurrence of ipsilateral pneumothorax during the median follow-up of 374 days (range, 37–1,992 days). These three patients were all teenage males at the time of the surgery.

Discussion Primary spontaneous pneumothorax occurs in young and otherwise healthy people. Outpatient treatment with a portable thoracic drainage device has a high success rate and a low admission rate, and allows the patient to continue their daily life. Thus, it may offer an improved quality of life for those who do not want to be immediately admitted due to business or school obligations. In our institution, needle aspiration is not performed as the initial intervention for the management of primary spontaneous pneumothorax due to the relatively low success rate and high admission rate. Tube drainage with a large-bore catheter (> 20F) under hospital admission was used in our institution until 2002, when Thoracic Egg became available for the treatment of primary spontaneous pneumothorax in Japan. Use of this portable thoracic drainage device has enabled us to provide outpatient management with a relatively high success rate and an acceptably low complication rate. Furthermore, outpatient treatment of primary spontaneous pneumothorax with a portable thoracic drainage device costs less than conventional tube drainage with hospital admission. Thus, a portable thoracic drainage device may be considered one of the first choices for the initial treatment of primary spontaneous pneumothorax. Due to the nature of the outpatient treatment of pneumothorax using a small-bore catheter, it is possible that the catheter may have been kinked or blocked while the patients were at home. A tension pneumothorax after the patient had returned home could be life threatening. Thus, patients were instructed to visit the clinic or call the clinic when they felt any discomfort while at home. As none of the patients experienced any such problems during outpatient treatment, we believe that our strategy is both safe and effective. Only one small randomized controlled study has compared a mini–chest tube (12F) and needle aspiration.7 In that study, admission rates at the first day of treatment were 52% (12/23) after needle aspiration and 28% (7/25) after mini– chest tube insertion, and this difference was not statistically significant. To date, no adequately sized randomized controlled trials have compared simple aspiration and small-bore catheter drainage for the treatment of primary spontaneous pneumothorax. The admission rate on the day of small-bore catheter insertion has been reported to be 4 to 28%.7,8,11 In the present study, the admission rate from the emergency room was only 2% on the day of insertion of a portable thoracic drainage device. Although each study has different criteria for discharge from the emergency department, this favorable result with a portable thoracic drainage device was perhaps due to the ease of insertion of a Thoracic Egg. The recurrence rate after treatment with a portable thoracic drainage device shown in this study was comparable

Karasaki et al.

with the recurrence rates after other conservative management approaches, which have been estimated to range from 28 to 54%.12,13 In this study, a portable thoracic drainage device was also effective in recurrent cases, although the recurrence rate increased. This result was compatible with previous reports that showed increased recurrence rates with recurrent pneumothoraces.2,14 On the contrary, the recurrence rate of spontaneous pneumothorax after surgical intervention is said to be approximately 1 to 11% after the first episode and higher after the second episode.4,13,14 The recurrence rate after surgery in this study was consistent with previous reports. In addition, the recurred cases after surgery in this study were all teenage males at the time of surgery, who have a higher risk of recurrence.15 Nonetheless, the recurrence rate after surgery was much lower than the recurrence rate of 34% after treatment with a portable thoracic drainage device in this study. It is important to explain both the merits and potential drawbacks of each treatment option, and the patient’s choice should play an essential role in decision making, including the timing of surgery. This study has several limitations. For example, it was a retrospective chart review. In this study, we focused on the success rate of outpatient treatment of primary spontaneous pneumothorax. Different studies have defined success somewhat differently.8,11 In addition, asymptomatic recurrence can be missed because it is not seen in our clinic. Large, welldesigned randomized controlled trials are required to obtain reliable data regarding outpatient treatment of primary spontaneous pneumothorax using a small-bore portable thoracic drainage device. In conclusion, outpatient treatment for primary spontaneous pneumothorax using a portable thoracic drainage device had a high success rate with few serious complications and an acceptable recurrence rate. While prospective trials are still needed, a portable thoracic drainage device may be one of the first choices for the initial treatment of primary spontaneous pneumothorax.

Conflict of Interest We declare that there are no conflicts of interest. Disclaimer The German Society for Thoracic and Cardiovascular Surgery (DGTHG) and The Thoracic and Cardiovascular Surgeon neither endorse nor discourage the use of the new technology described in this publication.

References 1 Gupta D, Hansell A, Nichols T, Duong T, Ayres JG, Strachan D.

Epidemiology of pneumothorax in England. Thorax 2000;55(8): 666–671 2 Cran IR, Rumball CA. Survey of spontaneous pneumothoraces in the Royal Air Force. Thorax 1967;22(5):462–465 3 Baumann MH, Strange C, Heffner JE, et al; AACP Pneumothorax Consensus Group. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest 2001;119(2):590–602

Thoracic and Cardiovascular Surgeon

Vol. 62

No. 6/2014

519

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

Outpatient Treatment for Primary Spontaneous Pneumothorax

Outpatient Treatment for Primary Spontaneous Pneumothorax

Karasaki et al.

4 MacDuff A, Arnold A, Harvey J; BTS Pleural Disease Guideline

10 Lee S, Park SY, Bae MK, et al. Efficacy of polyglycolic acid sheet after

Group. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010;65 (Suppl 2):ii18–ii31 De Leyn P, Lismonde M, Ninane V, et al. Guidelines Belgian Society of Pneumology. Guidelines on the management of spontaneous pneumothorax. Acta Chir Belg 2005;105(3):265–267 Fysh ET, Smith NA, Lee YC. Optimal chest drain size: the rise of the small-bore pleural catheter. Semin Respir Crit Care Med 2010; 31(6):760–768 Ho KK, Ong ME, Koh MS, Wong E, Raghuram J. A randomized controlled trial comparing minichest tube and needle aspiration in outpatient management of primary spontaneous pneumothorax. Am J Emerg Med 2011;29(9):1152–1157 Lai SM, Tee AK. Outpatient treatment of primary spontaneous pneumothorax using a small-bore chest drain with a Heimlich valve: the experience of a Singapore emergency department. Eur J Emerg Med 2012;19(6):400–404 Kurihara M, Kataoka H, Ishikawa A, Endo R. Latest treatments for spontaneous pneumothorax. Gen Thorac Cardiovasc Surg 2010; 58(3):113–119

thoracoscopic bullectomy for spontaneous pneumothorax. Ann Thorac Surg 2013;95(6):1919–1923 Hassani B, Foote J, Borgundvaag B. Outpatient management of primary spontaneous pneumothorax in the emergency department of a community hospital using a small-bore catheter and a Heimlich valve. Acad Emerg Med 2009;16(6):513–518 Baumann MH, Strange C. Treatment of spontaneous pneumothorax: a more aggressive approach? Chest 1997;112(3):789–804 Sawada S, Watanabe Y, Moriyama S. Video-assisted thoracoscopic surgery for primary spontaneous pneumothorax: evaluation of indications and long-term outcome compared with conservative treatment and open thoracotomy. Chest 2005; 127(6):2226–2230 Cardillo G, Facciolo F, Giunti R, et al. Videothoracoscopic treatment of primary spontaneous pneumothorax: a 6-year experience. Ann Thorac Surg 2000;69(2):357–361, discussion 361–362 Yabuki H, Tabata T, Sugawara T, Fukaya K, Fujimura S. The influence of difference of surgical procedure for the young spontaneous pneumothorax to the recurrence rate after surgery [in Japanese]. Kyobu Geka 2013;66(12):1033–1040

5

6

7

8

9

Thoracic and Cardiovascular Surgeon

Vol. 62

No. 6/2014

11

12 13

14

15

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

520

Copyright of Thoracic & Cardiovascular Surgeon is the property of Georg Thieme Verlag Stuttgart and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

Outcomes of outpatient treatment for primary spontaneous pneumothorax using a small-bore portable thoracic drainage device.

There is no consensus regarding the initial intervention for primary spontaneous pneumothorax. We report the outcomes of outpatient treatment for prim...
122KB Sizes 0 Downloads 4 Views