Reference: Marx et al. Simple Aspiration versus Drainage for Complete Pneumothorax: A Randomized Noninferiority Trial. Am J Respir Crit Care Med. 2023
Date: March 22, 2024
Guest Skeptic: Dr. Richard Malthaner holds the prestigious position of Chair/Head of the Division of Thoracic Surgery and serves as the Director of the Thoracic Robotic Program at Western University's Schulich School of Medicine and Dentistry. Dr. Malthaner currently serves as the Vice President of the Canadian Association of Thoracic Surgeons and is the founder of the Skeptik Thoracik Journal Club.
Case: A 25-year-old female medical student presents with right chest pain and dyspnea. Chest x-ray (CXR) shows a “complete pneumothorax.”
Background: The first time we got together to discuss chest tubes was on SGEM#129. That episode had two questions. The first question was in a trauma patient, how clinically useful is a CXR after putting in the chest tube?
The answer we came up with was to put the tube on the correct side, within the triangle of safety, and within the pleural space. Continue to obtain a CXR post chest tube knowing it will probably not change management. Be more concerned if the patient is doing poorly or the tube is not draining.
The second question we tried to answer was does chest tube location matter? The answer is that the part of the location that matters in these situations is that the chest tube is safely placed on the correct side and in the pleural space.
The next time were talking chest tubes was not in trauma patients but rather in patients with their first large spontaneous pneumothorax in SGEM#300. We only had one question asking if they all needed a chest tube. The bottom line for that episode was it's reasonable to provide conservative management in a patient with large first-time spontaneous pneumothoraxes if you can ensure close follow-up.
We have looked at other chest-related issues with other guest skeptics. SGEM#339 looked at the optimal anatomical location for needle decompression for tension pneumothorax with Dr. Rob Edmonds. That study did not support the claim that the second intercostal space-midclavicular line is thicker than the fourth/fifth intercostal space-anterior axial line.
The most recent time we have explored something involving chest tubes was with guest skeptic Dr. Chris Root (SGEM#355). We wanted to know if the size of the chest tube matters in hemodynamically stable patients with traumatic hemothorax. That was a multicenter, non-inferior, unblinded, randomized, parallel assignment comparison trial that reported small percutaneous catheters were non-inferior to large open chest tubes for traumatic hemothorax.
Patients can present with a spontaneous pneumothorax. This is defined as air in the pleural space between the lung and the chest wall with no obvious precipitating factor. It can occur in existing lung disease (secondary spontaneous pneumothorax) or with no known underlying lung pathology (primary spontaneous pneumothorax).
Chest tube drainage remains the reference first-line treatment of primary spontaneous pneumothorax, however, complications occur in 9–26% of such cases. A less invasive alternative approach is simple aspiration, which could be an option. The best way to manage a first primary spontaneous pneumothorax episode remains unclear.
Clinical Question: Is simple aspiration non-inferior to chest tube drainage for first-line lung expansion in patients with complete primary spontaneous pneumothorax?
Reference: Marx et al. Simple Aspiration versus Drainage for Complete Pneumothorax: A Randomized Noninferiority Trial. Am J Respir Crit Care Med. 2023
Population: Adults aged 18–50 years with a first episode of a symptomatic completed spontaneous pneumothorax for <48 hours. Complete was defined as total separation of the lung from the chest wall.
Exclusions: Tension pneumothorax, traumatic and recurrent pneumothorax,
The Skeptics Guide to Emergency Medicine