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Spontaneous pneumothorax: outpatient management with intercostal tube drainage A. Page,* md; R. CossETTE,f md; L. Dontigny,! md; R. LEVY,f md; C. MERCiER,t md; L. C. Pelletier,J md; A. Verdant,! md
Summary: In a series of 104 episodes pneumothorax 75% of episodes were managed successfully on an outpatient basis by observation (23.1 %) or by intercostal tube drainage using a flutter valve (51.9%). The patients of
Until 1972 most patients with spon¬ taneous pneumothorax who were seen at Hopital du Sacre-Coeur de Montreal were admitted for treatment. An im¬
males and in the fifth intercostal space
laterally in the females (Fig. 1). Underwater drainage was effected for ap¬ proximately 3 hours, then chest radio¬ portant increase in the number of cases graphy was ordered. When the lung in recent years has led us to modify was adequately reexpanded the underwater drainage was stopped, a flutter our policy: in 1970 we treated 22 pa¬ for whom this treatment was not tients for spontaneous pneumothorax; valve was connected to the chest tube successful were admitted to hospital; in 1971, 38 patients; in 1972, 44 pa¬ and the patient was sent home. 17 of them (16.3% of 104) were The flutter valve, also known as the treated surgically. Bleb suturing with tients; and in 1973, 91 patients. How¬ a stapling device and dry sponge ever, it is possible to treat most cases Heimlich1 valve (Bard-Parker, no. abrasion of the pleura was the operation of spontaneous pneumothorax on an 3460), is a simple device consisting of choice. outpatient basis after insertion of an essentially of a piece of latex rubber intercostal tube. tubing, one end of which is compressed Resume: Dans
une
serie de 104
episodes de pneumothorax spontane 75% des episodes ont ete traites avec
Patients and method of treatment
succes en externe ou par
Patients
par observation
drainage thoracique par (23.1%) tube, en employant la valve de Heimlich (51.9%). Les malades dont ce traitement n'a pas eu de succes ont ete admis a I'hdpital; 17 d'entre eux (16.3% des 104) ont ete operes.
L'operation de choix est la suture des d'emphyseme avec un appareil a autosuture metalHque, accompagnee d'irritation de la plevre parietale bulles
avec une
compresse seche.
From the cardiovascular and thoracic service, department of surgery, Hdpital du Sacre-Coeur de Montreal ?Associate clinical professor of surgery, department of surgery, University of Montreal; chief of the department of surgery, Hdpital du Sacre-Coeur de Montreal fAssistant clinical professor of surgery, department of surgery, University of Montreal; member of the cardiovascular and thoracic service, department of surgery, Hdpital du Sacre-Coeur de Montreal ^Assistant professor of research, department of surgery, University of Montreal; member of the cardiovascular and thoracic service, department of surgery, Hdpital du Sacr6-Coeur de Montreal Reprint requests to: Dr. A. Page\ Department of surgery, Hdpital du Sacre-Coeur, 5400 ouest, boulevard Gouin, Montreal, Que\ H4J 1C5
All 100 patients with spontaneous pneumothorax seen in the emergency department of our hospital from Jan¬ uary 1973 to February 1974 are in¬ cluded in this study. The average age was 27.3 years (range, 16 to 59 years); 75 were male and 25 were female; and 88 were smokers. There were 104 episodes of pneumothorax; for 25 pa¬ tients it was a recurrent episode. Eleven had bilateral episodes. The frequency of involvement of the right and left sides was equal. Initial treatment
Patients with a collapsed area of lung of 1 cm or less in diameter or an apical "cap" of 4 cm or less were treated conservatively: they were sent home after a short period of observa¬ tion. If the area of collapse was larger, intercostal tube drainage was instituted. Under local anesthesia a no. 16F trocar with catheter was inserted in the sec¬ ond intercostal space anteriorly in the
FIG. 1.Lateral intercostal tube and flutter valve.
CMA JOURNAL/MARCH 22, 1975/VOL. 112 707
and retains its flattened shape (Fig. 2). This end of the rubber tubing remains collapsed at rest. Positive pressure
in 26 (25%) of the 104 episodes of pneumothorax: because of persistent lung collapse in 20 cases, serious hemoexerted on inspiration permits trapped thorax in 3 cases, concurrent pneu¬ air to exit through the valve; negative monia in 1 case and multiple recur¬ intrapleural pressure in the absence of rences in 2 cases. trapped air causes the valve to close. It also permits drainage of fluid. The Results valve functions in any position. The Conservative treatment was success¬ patient who has a thoracostomy with a ful in 24 (23.1%) of the 104 episodes tube and valve in place is ambulatory, of pneumothorax. Tube thoracostomy and with a loose shirt or sweater the was necessary in all other cases; of tube and valve are inapparent. these 80 cases, outpatient management The patients who were treated by was sufficient in 54 (67.5%, or 51.9% of the 104 cases). Duration of drainage means of an intercostal tube and valve were seen 3 days later at the outpa¬ averaged 4.68 days (range, 1 to 18 tient clinic. The tube and valve were days). Therefore, of all 104 episodes, removed if the lung was reexpanded 77 (75%) were managed successfully and there was no air leak; otherwise on an outpatient basis and 26 (25%) they were left in place for another 3 required admission to hospital. Of the days. If an air leak persisted after 6 26 patients admitted to hospital 9 days, the patient was admitted to hos¬ (34.6%, or 8.7% of 104) responded pital. The flutter valve was removed to conservative management and 17 and water drainage begun, with a (65.4%, or 16.3% of 104) required negative pressure of 15 to 20 cm H20. an operation, either because of per¬ If the air leak persisted for several days sistent air leak (15 cases) or multiple surgery was considered. The operation recurrences (2 cases). Thoracotomy of choice was bleb suture with dry- was performed in 11 patients and me¬ sponge abrasion of the parietal pleura dian sternotomy in 6. through thoracotomy or, in certain Discussion cases, through median sternotomyj which permitted access to both right Various aspects of spontaneous and left pleural cavities in cases of pneumothorax, such as etiology, in¬ bilateral blebs. fluence of barometric pressure and Admission to hospital was required management, from the very conserva¬
tive to the very radical, have been totally reviewed in the literature.2"15 The large increase in the number of cases of spontaneous pneumothorax seen in our hospital in the last few years led us to reappraise our approach to the management of this condition. This increase was mainly a result of regionalization of health care in the Province of Quebec: in 1973, for exam¬ ple, 84 846 new patients were treated in our fast-growing emergency depart¬ ment and the incidence of spontaneous pneumothorax was 0.1%. Faced with this situation we have tried to rehabili¬ tate patients rapidly and to effect economy in the use of hospital beds. It is possible to treat 75% of patients with spontaneous pneumothorax on an outpatient basis; moreover, as soon as the chest tube is removed a patient can quickly return to full activity. The flutter valve we have used is simple, safe and efficient. After reexpansion of the lung, patients can be sent home regardless of persistent air leak and minimal hemothorax. At follow-up only patients with abnormalities such as persistent lung collapse, serious hemothorax or pneumonia need be hospitalized. No complications resulted from the outpatient management, except for one superficial wound infection 7 days after
removal of the tube. No antimicrobials
WORKSHOP ON WRITING FOR MEDICAL JOURNALS Tuesday, June 24, 1975 Palliser Hotel Calgary 9
.
to 5 p.m. Do you want to make your scientific more
a.m.
effective,
acceptable?
more
writing interesting, more principles of effect¬
Are you interested in the ively organizing medical papers and reports? . Do you want to learn how to prepare papers to convince editors, reviewers and readers? If so, attend a 1-day workshop to be held during the CMA annual meeting. Workshop will include discussion of preworkshop assignments and various aspects of medical writing. Faculty: David A. E. Shephard, M.B., F.R.C.P.(C) .
Associate scientific editor, CMAJ David Woods Consultant, Medical Communications Services . Registration limited to 25 participants.
. . .
FIG. 2.Flutter valve or Heimlich valve. 708 CMA JOURNAL/MARCH 22, 1975/VOL. 112
Deadline for registration: May 15, 1975. Fee: $40. For further details write to: Dr. David A. E. Shephard, .
Associate scientific editor, CANADIAN MEDICAL ASSOCIATION. Box 8650, Ottawa, Ont. K1G 0G8.
were given. Two patients treated conservatively subsequently required thoracostomy and intercostal tube drainage. Surgery was necessary in only a small proportion of our patients (16.3%). One indication for operative management on these patients was persistent air leak after 6 to 8 days with underwater drainage and negative pressure. The other indication was multiple recurrences, a third episode on one side or a second episode on the contralateral side. Hemothorax was not an indication for surgery is this series. In most cases thoracotomy was performed and the blebs were sutured at their base with a surgical stapling device and left in place. Dry-sponge abrasion of the parietal pleura was also done to promote adhesions. Median sternotomy is recommended only in young male patients with bilateral disease. There were no recurrences after operation.
sniffle...tick. .tick.. tick... sniffle .tick...tick...Otrivin..xick...tick ...tick..;tic ick...tick...tick... ck...sniff...tick. tick tick.
Spontaneous pneumothorax: outpatient management with intercostal tube drainage A. Page,* md; R. CossETTE,f md; L. Dontigny,! md; R. LEVY,f md; C. MERCiER,t md; L. C. Pelletier,J md; A. Verdant,! md
Summary: In a series of 104 episodes pneumothorax 75% of episodes were managed successfully on an outpatient basis by observation (23.1 %) or by intercostal tube drainage using a flutter valve (51.9%). The patients of
Until 1972 most patients with spon¬ taneous pneumothorax who were seen at Hopital du Sacre-Coeur de Montreal were admitted for treatment. An im¬
males and in the fifth intercostal space
laterally in the females (Fig. 1). Underwater drainage was effected for ap¬ proximately 3 hours, then chest radio¬ portant increase in the number of cases graphy was ordered. When the lung in recent years has led us to modify was adequately reexpanded the underwater drainage was stopped, a flutter our policy: in 1970 we treated 22 pa¬ for whom this treatment was not tients for spontaneous pneumothorax; valve was connected to the chest tube successful were admitted to hospital; in 1971, 38 patients; in 1972, 44 pa¬ and the patient was sent home. 17 of them (16.3% of 104) were The flutter valve, also known as the treated surgically. Bleb suturing with tients; and in 1973, 91 patients. How¬ a stapling device and dry sponge ever, it is possible to treat most cases Heimlich1 valve (Bard-Parker, no. abrasion of the pleura was the operation of spontaneous pneumothorax on an 3460), is a simple device consisting of choice. outpatient basis after insertion of an essentially of a piece of latex rubber intercostal tube. tubing, one end of which is compressed Resume: Dans
une
serie de 104
episodes de pneumothorax spontane 75% des episodes ont ete traites avec
Patients and method of treatment
succes en externe ou par
Patients
par observation
drainage thoracique par (23.1%) tube, en employant la valve de Heimlich (51.9%). Les malades dont ce traitement n'a pas eu de succes ont ete admis a I'hdpital; 17 d'entre eux (16.3% des 104) ont ete operes.
L'operation de choix est la suture des d'emphyseme avec un appareil a autosuture metalHque, accompagnee d'irritation de la plevre parietale bulles
avec une
compresse seche.
From the cardiovascular and thoracic service, department of surgery, Hdpital du Sacre-Coeur de Montreal ?Associate clinical professor of surgery, department of surgery, University of Montreal; chief of the department of surgery, Hdpital du Sacre-Coeur de Montreal fAssistant clinical professor of surgery, department of surgery, University of Montreal; member of the cardiovascular and thoracic service, department of surgery, Hdpital du Sacre-Coeur de Montreal ^Assistant professor of research, department of surgery, University of Montreal; member of the cardiovascular and thoracic service, department of surgery, Hdpital du Sacr6-Coeur de Montreal Reprint requests to: Dr. A. Page\ Department of surgery, Hdpital du Sacre-Coeur, 5400 ouest, boulevard Gouin, Montreal, Que\ H4J 1C5
All 100 patients with spontaneous pneumothorax seen in the emergency department of our hospital from Jan¬ uary 1973 to February 1974 are in¬ cluded in this study. The average age was 27.3 years (range, 16 to 59 years); 75 were male and 25 were female; and 88 were smokers. There were 104 episodes of pneumothorax; for 25 pa¬ tients it was a recurrent episode. Eleven had bilateral episodes. The frequency of involvement of the right and left sides was equal. Initial treatment
Patients with a collapsed area of lung of 1 cm or less in diameter or an apical "cap" of 4 cm or less were treated conservatively: they were sent home after a short period of observa¬ tion. If the area of collapse was larger, intercostal tube drainage was instituted. Under local anesthesia a no. 16F trocar with catheter was inserted in the sec¬ ond intercostal space anteriorly in the
FIG. 1.Lateral intercostal tube and flutter valve.
CMA JOURNAL/MARCH 22, 1975/VOL. 112 707
and retains its flattened shape (Fig. 2). This end of the rubber tubing remains collapsed at rest. Positive pressure
in 26 (25%) of the 104 episodes of pneumothorax: because of persistent lung collapse in 20 cases, serious hemoexerted on inspiration permits trapped thorax in 3 cases, concurrent pneu¬ air to exit through the valve; negative monia in 1 case and multiple recur¬ intrapleural pressure in the absence of rences in 2 cases. trapped air causes the valve to close. It also permits drainage of fluid. The Results valve functions in any position. The Conservative treatment was success¬ patient who has a thoracostomy with a ful in 24 (23.1%) of the 104 episodes tube and valve in place is ambulatory, of pneumothorax. Tube thoracostomy and with a loose shirt or sweater the was necessary in all other cases; of tube and valve are inapparent. these 80 cases, outpatient management The patients who were treated by was sufficient in 54 (67.5%, or 51.9% of the 104 cases). Duration of drainage means of an intercostal tube and valve were seen 3 days later at the outpa¬ averaged 4.68 days (range, 1 to 18 tient clinic. The tube and valve were days). Therefore, of all 104 episodes, removed if the lung was reexpanded 77 (75%) were managed successfully and there was no air leak; otherwise on an outpatient basis and 26 (25%) they were left in place for another 3 required admission to hospital. Of the days. If an air leak persisted after 6 26 patients admitted to hospital 9 days, the patient was admitted to hos¬ (34.6%, or 8.7% of 104) responded pital. The flutter valve was removed to conservative management and 17 and water drainage begun, with a (65.4%, or 16.3% of 104) required negative pressure of 15 to 20 cm H20. an operation, either because of per¬ If the air leak persisted for several days sistent air leak (15 cases) or multiple surgery was considered. The operation recurrences (2 cases). Thoracotomy of choice was bleb suture with dry- was performed in 11 patients and me¬ sponge abrasion of the parietal pleura dian sternotomy in 6. through thoracotomy or, in certain Discussion cases, through median sternotomyj which permitted access to both right Various aspects of spontaneous and left pleural cavities in cases of pneumothorax, such as etiology, in¬ bilateral blebs. fluence of barometric pressure and Admission to hospital was required management, from the very conserva¬
tive to the very radical, have been totally reviewed in the literature.2"15 The large increase in the number of cases of spontaneous pneumothorax seen in our hospital in the last few years led us to reappraise our approach to the management of this condition. This increase was mainly a result of regionalization of health care in the Province of Quebec: in 1973, for exam¬ ple, 84 846 new patients were treated in our fast-growing emergency depart¬ ment and the incidence of spontaneous pneumothorax was 0.1%. Faced with this situation we have tried to rehabili¬ tate patients rapidly and to effect economy in the use of hospital beds. It is possible to treat 75% of patients with spontaneous pneumothorax on an outpatient basis; moreover, as soon as the chest tube is removed a patient can quickly return to full activity. The flutter valve we have used is simple, safe and efficient. After reexpansion of the lung, patients can be sent home regardless of persistent air leak and minimal hemothorax. At follow-up only patients with abnormalities such as persistent lung collapse, serious hemothorax or pneumonia need be hospitalized. No complications resulted from the outpatient management, except for one superficial wound infection 7 days after
removal of the tube. No antimicrobials
WORKSHOP ON WRITING FOR MEDICAL JOURNALS Tuesday, June 24, 1975 Palliser Hotel Calgary 9
.
to 5 p.m. Do you want to make your scientific more
a.m.
effective,
acceptable?
more
writing interesting, more principles of effect¬
Are you interested in the ively organizing medical papers and reports? . Do you want to learn how to prepare papers to convince editors, reviewers and readers? If so, attend a 1-day workshop to be held during the CMA annual meeting. Workshop will include discussion of preworkshop assignments and various aspects of medical writing. Faculty: David A. E. Shephard, M.B., F.R.C.P.(C) .
Associate scientific editor, CMAJ David Woods Consultant, Medical Communications Services . Registration limited to 25 participants.
. . .
FIG. 2.Flutter valve or Heimlich valve. 708 CMA JOURNAL/MARCH 22, 1975/VOL. 112
Deadline for registration: May 15, 1975. Fee: $40. For further details write to: Dr. David A. E. Shephard, .
Associate scientific editor, CANADIAN MEDICAL ASSOCIATION. Box 8650, Ottawa, Ont. K1G 0G8.
were given. Two patients treated conservatively subsequently required thoracostomy and intercostal tube drainage. Surgery was necessary in only a small proportion of our patients (16.3%). One indication for operative management on these patients was persistent air leak after 6 to 8 days with underwater drainage and negative pressure. The other indication was multiple recurrences, a third episode on one side or a second episode on the contralateral side. Hemothorax was not an indication for surgery is this series. In most cases thoracotomy was performed and the blebs were sutured at their base with a surgical stapling device and left in place. Dry-sponge abrasion of the parietal pleura was also done to promote adhesions. Median sternotomy is recommended only in young male patients with bilateral disease. There were no recurrences after operation.
sniffle...tick. .tick.. tick... sniffle .tick...tick...Otrivin..xick...tick ...tick..;tic ick...tick...tick... ck...sniff...tick. tick tick.
