Elsevier

Annals of Emergency Medicine

Volume 64, Issue 3, September 2014, Pages 222-228
Annals of Emergency Medicine

Pulmonary/original research
Ambulatory Management of Large Spontaneous Pneumothorax With Pigtail Catheters

Presented as a poster at the European Respiratory Society Congress, Barcelona, Spain, in September 2013.
https://doi.org/10.1016/j.annemergmed.2013.12.017Get rights and content

Study objective

There is no consensus about the management of large spontaneous pneumothoraces. Guidelines recommend either needle aspiration or chest tube drainage and most patients are hospitalized. We assess the efficiency of ambulatory management of large spontaneous pneumothoraces with pigtail catheters.

Methods

From February 2007 to January 2011, all primary and secondary large spontaneous pneumothoraces from Lorient's hospital (France) were managed with pigtail catheters with a 1-way valve. The patients were discharged immediately and then evaluated every 2 days according to a specific algorithm.

Results

Of the 132 consecutive patients (110 primary, 22 secondary), 103 were exclusively managed as outpatients, with full resolution of the pneumothorax by day 2 or 4, which represents an ambulatory success rate of 78%. Mean time (SD) of drainage was 3.4 days (1.8). Seven patients were initially hospitalized but quickly discharged and had full resolution by day 2 or 4, leading to a total success rate of 83%. The use of analgesics was low. The 1-year recurrence rate was 26%. If successful, this outpatient management is potentially cost saving, with a mean cost of $926, assuming up to 2 outpatient visits and 1 chest radiograph, compared with $4,276 if a chest tube was placed and the patient was admitted to the hospital for 4 days.

Conclusion

Ambulatory management with pigtail catheters with 1-way valves could be a reasonable first-line of treatment for large spontaneous pneumothoraces. Compared with that of other studies, our protocol does not require hospitalization and is cost saving.

Introduction

Spontaneous pneumothoraces are common1; however, there is no consensus about their management. Three major articles contain guidelines for the management of spontaneous pneumothoraces, but they differ both in definition and management of large spontaneous pneumothoraces.2, 3, 4 Although the American College of Chest Physicians recommends the use of small-bore catheters, the British Thoracic Society and Belgian Society of Pulmonary Diseases recommend needle aspiration as the first step, followed by chest tube drainage in case of at least 1 unsuccessful needle aspiration attempt.

Editor's Capsule Summary

What is already known on this topic

Patients with large spontaneous pneumothorax have traditionally been managed inhospital with a chest tube. Small studies have described outpatient management with pigtail catheter and 1-way valve.

What question this study addressed

Can patients with large spontaneous pneumothoraces be safely managed as outpatients with pigtail catheter and 1-way valve?

What this study adds to our knowledge

In this retrospective single-center series of 132 consecutive patients, approximately 80% were treated successfully without hospital admission.

How this is relevant to clinical practice

If confirmed in randomized trials in other centers, outpatient management of large spontaneous pneumothoraces in this manner may become preferred first-line treatment.

Pigtail catheters are worth investigating as a treatment procedure for managing pneumothoraces because of their limited invasiveness. Marquette et al5 published a pilot study in 2006 with a simplified management of primary spontaneous pneumothoraces in hospitalized patients, using a small-caliber indwelling catheter connected to a 1-way Heimlich valve. The same group recently published a study of a series of 48 patients with a first episode of large primary spontaneous pneumothoraces treated with pigtail catheter and 1-way valve, in which 18 (37%) were treated as outpatients, with good efficiency and safety.6 Other studies with approximately 50 patients each have shown that ambulatory management of primary spontaneous pneumothoraces using small catheters connected to a 1-way valve is possible.7, 8, 9, 10

We report here a series of 132 patients with both primary and secondary spontaneous pneumothoraces treated in an ambulatory setting with pigtail catheters. Our aims were to assess the success rate of exclusive outpatient management of spontaneous pneumothoraces (primary outcome) and evaluate 1-year recurrence rate, analgesics consumption, safety, and crude economic effect (secondary outcomes).

Section snippets

Selection of Participants

We collected data on all consecutive patients older than 16 years and with large spontaneous pneumothoraces treated in the Emergency Department and the Respiratory Diseases Department of the Centre Hospitalier de Bretagne Sud (800 beds; Lorient, France) from February 2007 to January 2011. Traumatic and iatrogenic pneumothoraces were excluded.11 The definition of “large” pneumothorax was based on either American College of Chest Physicians (distance from apex to cupola ≥3 cm) or British Thoracic

Characteristics of Study Subjects

We included all 132 consecutive large spontaneous pneumothoraces, detailed in Figure 2. No pneumothoraces were missed because pulmonologists were on call and could be contacted day and night if a patient presented with a large spontaneous pneumothorax. The clinical characteristics of the patients are detailed in Table 1. The mean age of our patients was 32 years (SD 15; range 16 to 82 years). The mean duration of pigtail drainage was 3.4 days (SD 1.8; range 1 to 12 days).

Main Results

The 22 secondary

Limitations

Our retrospective study has some limitations, such as its monocentric setting, the loss of patients during follow-up, that the recurrence data for 1 year relied on retrospective recall of pneumothorax from patients, the absence of a control group, success rate by provider, and standardized pain evaluation scales. Also, the number of patients with secondary spontaneous pneumothorax was small; it is therefore difficult to draw conclusions from this group. The same limitation (underpowered study)

Discussion

To our knowledge, this is the largest case series of ambulatory management for spontaneous pneumothoraces managed with pigtail catheters with 1-way valves. The success rate was 78% of patients managed exclusively as outpatients, reaching 84% in patients with first episode of primary spontaneous pneumothorax, and the total success rate in the entire series was 83%. In addition, analgesic use was low. This protocol was less expensive than our previous traditional chest tube drainage management

References (20)

There are more references available in the full text version of this article.

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Please see page 223 for the Editor's Capsule Summary of this article.

Supervising editor: Allan B. Wolfson, MD

Author contributions: FV, LS, BD, and SJ were responsible for the literature search. FV, CR, and SJ were responsible for figures. FV, LS, YR, BD, and SJ were responsible for data collection. All authors were responsible for data analysis, data interpretation, and writing and final approval of the article. SJ takes responsibility for the paper as a whole.

Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. The Centre d'études pneumologiques funded the medical editing service.

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