SGEM#300: The Lung is Up Where it Belongs – With or Without a Chest Tube

Date: August 27th, 2020 Guest Skeptic: Dr. Malthaner is the Chair/Chief of the Division of Thoracic Surgery, Director of Thoracic Surgery Research and Simulation, and Professor in the Departments of Surgery, Oncology, and Epidemiology and Biostatistics at the Schulich School of Medicine and Dentistry and Western University. Rick is also the founder of Western University’s Department of Surgery Journal Club and runs The Skeptik Thoracik Journal Club. Reference: Brown et al. Conservative versus Interventional Treatment for Spontaneous Pneumothorax. NEJM 2020 Case: A 49-year-old healthy male electrician presents to the emergency room with right chest pain and dyspnea. The work-up reveals a diagnosis of a right pneumothorax confirmed by chest x-ray (CXR). What do you do? Background: A patient with a pneumothorax is a common presentation to the emergency department. Pneumothoraxes can be broken down into either primary or secondary. Primary pneumothorax occurs in healthy people. Secondary pneumothoraxes are associated with underlying lung disease. There is considerable heterogeneity in the management of primary spontaneous pneumothoraxes, but the most common treatment is interventional drainage, sometimes progressing to surgical intervention. However, the insertion of a chest tube is often painful and can cause organ injury, bleeding, and infection. An alternative approach is conservative management, with intervention reserved for patients for whom the pneumothorax becomes physiologically significant. I covered in the Skeptik Thoracik Journal Club which can be viewed on YouTube. Clinical Question: Does everyone with a large first-time spontaneous pneumothorax need a chest tube? Reference: Brown et al. Conservative versus Interventional Treatment for Spontaneous Pneumothorax. NEJM 2020 Population: Patients 14 to 50 years of age with a unilateral primary spontaneous pneumothorax of 32% or more on chest radiography according to the Collins method. Exclusion: Previous primary spontaneous pneumothorax on the same side Secondary pneumothorax (defined as occurring in the setting of acute trauma or underlying lung disease including asthma with preventive medications or symptoms in the preceding two years) Coexistent hemothorax Bilateral pneumothorax “Tension’ pneumothorax” (systolic BP <90 mmHg, mean arterial pressure <65 mmHg, or shock index HR/SBP ≥1) Pregnancy at time of enrolment Social circumstances (inadequate support after discharge to re-attend hospital if required or unlikely to present for study follow up) Planned air travel within the following 12 weeks Intervention: A small chest tube (≤12 French) was inserted and attached to an underwater seal, without suction and a CXR was obtained one hour later. If the lung had re-expanded and the underwater drain no longer bubbled, the drain was closed with the use of a three-way stopcock. Four hours later, if the patient’s condition was stable and a repeat CXR showed that the pneumothorax had not recurred, the drain was removed, and the patient was discharged. If the initial drain insertion did not result in resolution on CXR or if the pneumothorax recurred under observation, the stopcock was opened, the underwater seal drainage was recommenced, and the patient was admitted. Subsequent interventions were at the discretion of the attending clinician. Comparison: Patients were observed for a minimum of four hours before a repeat CXR was obtained.After observation, if patients did not receive supplementary oxygen and were walking comfortably, they were discharged with analgesia and written instructions. Interventions were allowed in the conservative-management protocol under five conditions: Clinically significant symptoms persisted despite adequate analgesia; Chest pain or dyspnea prevented mobilization; Patient was unwilling to continue with conservative treatment;