May 27, 2020

Take Home Points
  • Small to Moderate Size Pneumothorax - consider managing conservatively with observation (need to make sure consulting services on same page)
  • Needle aspiration for spontaneous pneumothorax recommend by British Thoracic and European Respiratory Societies
  • 1 in 5 patients requiring a chest tube will suffer complications - many are iatrogenic in nature. Practice procedure via simulation 
  • Chest tubes placed for traumatic pneumothoraces should get prophylactic antibiotics
  • When deciding on treatment strategy, discuss with your consultants and make sure you have institutional buy-in.

March 12, 2020

Background: Most published clinical guidelines on the management of primary spontaneous pneumothorax (PSP) advocate for a conservative approach of observation for small asymptomatic pneumothoraces (PTX).(1,2) However, procedural re-expansion with a catheter or chest tube is recommended for all large pneumothoraces, regardless of symptomatology or clinical stability.(1) More recently, smaller chest tubes (i.e. pigtail catheters) have been used as this can potentially cause less pain. Typically, patients who get chest tubes or pigtail catheters require hospitalization for management of the tube. But, chest tubes are not without risk: there are multiple reports in the literature describing terrible consequences of chest tubes including bleeding, infections and empyemas, and misplacement into vital organs like the liver, spleen, and heart.(3-5) An alternative approach to this invasive procedure is to do nothing, unless the pneumothorax becomes physiologically significant. In an effort to reduce these risks and discomfort to the patient, the clinical quandary becomes: can a large pneumothorax be managed using a conservative observation-only approach, without placement of catheters or chest tubes? To date there have been no randomized clinical trials comparing these two polar opposite management strategies until now (The PSP Trial).
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