Ep 158 Management of Primary Spontaneous Pneumothorax

There is perhaps no single diagnosis where we see such a huge practice variation than in the management of spontaneous pneumothorax. Even the definition of what a large, tube-in-the-chest-worthy pneumothorax is different depending on where you practice. Management options for small and large spontaneous pneumothorax are all over the place – observation alone, pigtail catheter with Heimlich valve, needle aspiration, large-bore chest tube, underwater seal or suction. There are significant complications associated with each of these options. What’s the best approach to the management of spontaneous pneumothorax? Dr. Gil Yehudaiff, EM physician from North York General in Toronto and Dr. Mehdi Tahiri, thoracic surgeon from McGill University in Montreal and Anton answer questions such as: what is the role of PoCUS in the diagnosis and management of spontaneous pneumothorax? Which large pneumothoraces can be managed without needle aspiration or a chest tube? What are the most common reasons for small-bore pigtail catheter failure? When can a chest tube be safely removed and how should it be removed safely? How often do CXRs need to be repeated in patients with spontaneous pneumothorax? and many more... Podcast production, sound design & editing by Anton Helman; voice editing by Sheza Qayyam Written Summary and blog post by Humna Amjad & Gil Yehudaiff; edited by Anton Helman July, 2021 Cite this podcast as: Helman, A. Tahiri, M. Yehudaiff, G. Management of Spontaneous Pneumothorax. Emergency Medicine Cases. July, 2021. https://emergencymedicinecases.com/management-spontaneous-pneumothorax. Accessed [date] The content of this summary and podcast refers only to the patient with a primary spontaneous pneumothorax under the age of 50. The following does not apply to the patient with a coexisting hemothorax, secondary pneumothorax (eg. COPD, lung cancer), hydrothorax, iatrogenic pneumothorax, traumatic pneumothorax or tension pneumothorax. What is the role of PoCUS in the diagnosis and management of spontaneous pneumothorax? PoCUS has excellent test characteristics for the diagnosis of pneumothorax with a sensitivity of 90.9% and specificity of 98.2% based on pooled data. While upright CXR is also very accurate for the diagnosis of clinically significant pneumothorax, supine CXR has been found to have a sensitivity of only 50.2%. Since most trauma patients remain in a supine position during their ED evaluation, POCUS is most useful as part of E-FAST when a dichotomous answer as to whether or not the patient has a pneumothorax is required urgently. In the setting of spontaneous non-traumatic pneumothorax, PoCUS has a limited role as there is not enough evidence to suggest that PoCUS can be used to accurately quantify the size of the pneumothorax, and current guidelines are based primarily on CXR size measurements of the pneumothorax. Attempts have been made to quantify pneumothorax volume using  PoCUS. A study in 2014 in Italy compared lung ultrasound to CXR and CT for quantifying pneumothorax volume. They found that using a Lung Point at the mid-axillary line could help differentiate between small or large pneumothorax based on guideline CXR definitions. However, the accuracy was best for PoCUS for small pneumothoraces only. PoCUS Cases: Pneumothorax Does size matter when it comes to spontaneous pneumothorax management? Defining the size of a pneumothorax guides subsequent management decisions. Unfortunately there is no agreed upon universal definition of large pneumothorax, with several accepted definitions: * The American College of Chest Physicians - apex-cupola distance >3 cm