>Journal Club Report – 28th Feb 2015

Ambulatory management of large spontaneous pneumothorax with pigtail catheters.

Hosted and Appraised by Dr David Lewis

Questions reviewed by: Dr Robin Clouston PGY2 and Fraser Mackay Med3

Paper

Voisin F, Sohier L, Rochas Y, Kerjouan M, Ricordel C, Belleguic C, Desrues B, Jouneau S. Ambulatory management of large spontaneous pneumothorax with pigtail catheters. Ann Emerg Med. 2014 Sep;64(3):222-8. PMID: 24439715.

http://www.annemergmed.com/article/S0196-0644(13)01711-3/fulltext

Abstract

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.

Questions

http://www.annemergmed.com/article/S0196-0644(14)00619-2/fulltext

 

Answers

http://www.annemergmed.com/article/S0196-0644(14)01303-1/fulltext

 

SJRHEM Journal Club Appraisal

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SJRHEM Journal Club Discussion

  • It was generally felt to be a good pragmatic study, that was well presented
  • This approach is already commonplace in Canada
  • Some SJRH Emergency Physicians are already adopting an ambulatory approach to the management of pneumothorax (PTX)
  • It was felt that with some modification we could implement a guideline for the ambulatory management of pneumothorax
  • It was accepted that this was a retrospective case series and that it did not answer all the questions. However they did demonstrate a lack of harm to the 138  patients that they managed this way
  • We felt uncomfortable with the anterior (2nd/3rd ICS, MCL) approach to chest tube placement and preferred the traditional (anterior to mid axillary line)
  • We felt uncomfortable with the lack of post procedure CXR prior to discharge
  • Correspondence form SJRH Thoracic Surgeon
    • He was surprised this was considered a novel approach. It has been used for many years in Canada
    • He is not overly keen on Needle Aspiration – due to failure to resolve PTX
    • Although he uses the Cook Straight PTX set, he agrees that the Cook Seldinger Pigtail would be an appropriate alternative provided the user is appropriately experienced.
    • He does not run a regular clinic for follow up, so ambulatory PTX patients would need to be managed within the ED or another service.
  • We agreed to try source the smaller Cook Seldinger Pigtail catheters (8.5Fr)
  • We agreed to look at ways of registering procedures on the ED i3 Discharge summary
  • We agreed to work with Dr DeSousa to develop an evidence based guideline for the management os spontaneous PTX that would include an ambulatory component
  • We agreed to explore the possibility of including SJRH Pulmonologists in the follow up process
  • It was felt that the SIGN – Considered Judgement Proforma was a useful tool when considering a change in practice.

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