Timing of Invasive Procedures in Therapy for Primary and Secondary Spontaneous Pneumothorax Ronald Andreas
Schoenenberger, MD;
Walter Emil Haefeli, MD;
\s=b\Timing of invasive procedures during chest tube therapy in spontaneous pneumothorax is undefined. Evaluation of 115 patients with primary and secondary spontaneous pneumothorax treated with tube thoracostomy revealed nearly maximal healing rates after 48 hours without a relevant increase if drainage was maintained for up to 10 days. In secondary spontaneous pneumothorax, a significantly lower healing rate was observed after 48 hours compared with primary spontaneous pneumothorax (60% vs 82%). Therapeutic success was not predictable by single clinical variables available at admission (eg, age, gender, and smoking habits) nor by their combinations. Recurrence rates were 30% in both primary and secondary spontaneous pneumothorax. Hospital stay averaged 6 days in primary and 15 days in secondary spontaneous pneumothorax. Considering their efficacy and the low incidence of complications, the early use of invasive procedures such as surgical pleurectomy, after 48 hours of persistent gas leaking, seems justified. Shorter in-patient care and lower recurrence rates may result.
(Arch Surg. 1991;126:764-766)
of symptomatic pneumothorax the insertion of intercostal tube and drainage The standard of ipsilateral underwater seal.1-2 High treatment
is
through
an
rates to 70%) and contralateral (10% to 15%) recurrences after treatment with bed rest and observation or tube thoan
(25%
racostomy are common.3"6 More efficient, although inva¬ sive, procedures, such as surgical pleurectomy, are well
accepted in patients with a second ipsilateral recurrence and in cases of a contralateral relapse.78 In patients with the first episode or the first ipsilateral recurrence, data re¬ garding the time course and overall rate of healing with simple chest tube therapy are sparse, and, in the case of treatment failure, the timing of a more invasive procedure remains unclear. At our institution, the standard treatment for the first pneumothorax due to episodes of primary and secondary chronic obstructive lung disease and for the first recur¬ rence of primary spontaneous pneumothorax is chest tube drainage for up to 10 days. To assess the duration of gas leak under continuous suction therapy and to define the appropriate time for more invasive procedures, the charts Accepted for publication November 23, 1990. From the Department of Internal Medicine, Medical Intensive Care Unit, University Hospital (Kantonsspital), Basel, Switzerland. Reprint requests to the Department of Internal Medicine, University Hospital (Kantonsspital), Petersgraben 4, CH-4031 Basel,
Switzerland (Dr
Schoenenberger).
Philipp Weiss, MD;
Rudolf Fritz Ritz, MD
patients admitted for spontaneous pneumothorax during a 7-year period were reviewed. of all
PATIENTS AND METHODS
Patients The computer-based file of the Division of Medical Intensive Care at the University Hospital of Basel (Switzerland) was screened for the 7-year period from January 1982 to December 1988 for the discharge diagnosis of pneumothorax. A total of 253 patients were identified. Patients were included in this analysis if the following criteria were met: (1) roentgenographic confir¬ mation of pneumothorax (lung collapse >20%); (2) first event or first ipsilateral recurrence of primary spontaneous pneumotho¬ rax or first event of secondary spontaneous pneumothorax due to chronic obstructive pulmonary disease; and (3) full adherence to "standard treatment" (described below). Of the total of 253 patients, 45 had a iatrogenic pneumothorax, 10 had a traumatic pneumothorax, and eight had a pneumothorax due to mechanical ventilation; the remaining 190 patients had a spontaneous pneumothorax. Forty patients with a second or higher-grade recurrence were routinely allocated to undergo early surgery or thoracoscopy, and 15 patients with secondary spontaneous pneumothorax due to reasons other than chronic obstructive pulmonary disease were excluded. In 18 patients, standard treatment had not been adhered to, and additional mea¬ sures were taken before completion of the full duration of suction. In two cases in which lung collapse was less than 20%, no chest tube had been inserted. For the remaining 115 patients who met all inclusion criteria, demographic characteristics, duration of hospital stay, and occurrence of relapses within the observation period of 7 years were recorded. To evaluate the duration of gas leak, all nursing protocols were reviewed.
Standard Treatment of Pneumothorax After roentgenographic confirmation of pneumothorax, a 20F to 24F plastic chest tube (Argyle, Sherwood Medical, Tullamore, Ireland) was inserted into the fifth or sixth intercostal space in the midaxillary line. The tube was attached to a closed two-bottle drainage system. After 20 to 30 minutes, gradually increasing suction was applied to a maximum of 25 cm H20. The intercostal tube was left in place and under suction for up to 10 days, and the presence or absence of air bubbling was recorded regularly by trained intensive care nurses. If the gas leak stopped sooner, suction was continued for 24 hours and then the tube was clamped for another day. Unless roentgenography or gas egress during a short trial of suction demonstrated persistence or recurrence of pneumothorax, the tube was removed and the patient discharged after a 24-hour observation period. In cases of treatment failure at the end of the 10-day suction period, surgical pleurectomy or tho¬ racoscopy with insufflation of talc was performed.
Statistical Methods The data were analyzed with the SYSTAT statistical system for microcomputers.9 For comparison of continuous data, the Stu-
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/28/2015
Descriptive Features of Patients* PPT, Variable No. of
First
Event
Recurrence
72
patients
SPT,
PPT,
First
PPT,
First
All
Event 20
95
23
69.6±8.9t
81.9
32.6 11.7 82.6
33.5±13.3
Gender, M/F
64/8
18/5
72/13
Side of pneumothorax, L/R
39/33 77.8
10/13 65.3
49/46
7/134
74.7
85.0*
46.6 ±89.9
41.9 ±80.9
45.6 ±87.3
99.5±120.3t
6.3±3.7
6.4±3.5
6.3 ±3.6
15.0±14.3t
Mean ± SD age, y %
Schoenenberger, MD;
Walter Emil Haefeli, MD;
\s=b\Timing of invasive procedures during chest tube therapy in spontaneous pneumothorax is undefined. Evaluation of 115 patients with primary and secondary spontaneous pneumothorax treated with tube thoracostomy revealed nearly maximal healing rates after 48 hours without a relevant increase if drainage was maintained for up to 10 days. In secondary spontaneous pneumothorax, a significantly lower healing rate was observed after 48 hours compared with primary spontaneous pneumothorax (60% vs 82%). Therapeutic success was not predictable by single clinical variables available at admission (eg, age, gender, and smoking habits) nor by their combinations. Recurrence rates were 30% in both primary and secondary spontaneous pneumothorax. Hospital stay averaged 6 days in primary and 15 days in secondary spontaneous pneumothorax. Considering their efficacy and the low incidence of complications, the early use of invasive procedures such as surgical pleurectomy, after 48 hours of persistent gas leaking, seems justified. Shorter in-patient care and lower recurrence rates may result.
(Arch Surg. 1991;126:764-766)
of symptomatic pneumothorax the insertion of intercostal tube and drainage The standard of ipsilateral underwater seal.1-2 High treatment
is
through
an
rates to 70%) and contralateral (10% to 15%) recurrences after treatment with bed rest and observation or tube thoan
(25%
racostomy are common.3"6 More efficient, although inva¬ sive, procedures, such as surgical pleurectomy, are well
accepted in patients with a second ipsilateral recurrence and in cases of a contralateral relapse.78 In patients with the first episode or the first ipsilateral recurrence, data re¬ garding the time course and overall rate of healing with simple chest tube therapy are sparse, and, in the case of treatment failure, the timing of a more invasive procedure remains unclear. At our institution, the standard treatment for the first pneumothorax due to episodes of primary and secondary chronic obstructive lung disease and for the first recur¬ rence of primary spontaneous pneumothorax is chest tube drainage for up to 10 days. To assess the duration of gas leak under continuous suction therapy and to define the appropriate time for more invasive procedures, the charts Accepted for publication November 23, 1990. From the Department of Internal Medicine, Medical Intensive Care Unit, University Hospital (Kantonsspital), Basel, Switzerland. Reprint requests to the Department of Internal Medicine, University Hospital (Kantonsspital), Petersgraben 4, CH-4031 Basel,
Switzerland (Dr
Schoenenberger).
Philipp Weiss, MD;
Rudolf Fritz Ritz, MD
patients admitted for spontaneous pneumothorax during a 7-year period were reviewed. of all
PATIENTS AND METHODS
Patients The computer-based file of the Division of Medical Intensive Care at the University Hospital of Basel (Switzerland) was screened for the 7-year period from January 1982 to December 1988 for the discharge diagnosis of pneumothorax. A total of 253 patients were identified. Patients were included in this analysis if the following criteria were met: (1) roentgenographic confir¬ mation of pneumothorax (lung collapse >20%); (2) first event or first ipsilateral recurrence of primary spontaneous pneumotho¬ rax or first event of secondary spontaneous pneumothorax due to chronic obstructive pulmonary disease; and (3) full adherence to "standard treatment" (described below). Of the total of 253 patients, 45 had a iatrogenic pneumothorax, 10 had a traumatic pneumothorax, and eight had a pneumothorax due to mechanical ventilation; the remaining 190 patients had a spontaneous pneumothorax. Forty patients with a second or higher-grade recurrence were routinely allocated to undergo early surgery or thoracoscopy, and 15 patients with secondary spontaneous pneumothorax due to reasons other than chronic obstructive pulmonary disease were excluded. In 18 patients, standard treatment had not been adhered to, and additional mea¬ sures were taken before completion of the full duration of suction. In two cases in which lung collapse was less than 20%, no chest tube had been inserted. For the remaining 115 patients who met all inclusion criteria, demographic characteristics, duration of hospital stay, and occurrence of relapses within the observation period of 7 years were recorded. To evaluate the duration of gas leak, all nursing protocols were reviewed.
Standard Treatment of Pneumothorax After roentgenographic confirmation of pneumothorax, a 20F to 24F plastic chest tube (Argyle, Sherwood Medical, Tullamore, Ireland) was inserted into the fifth or sixth intercostal space in the midaxillary line. The tube was attached to a closed two-bottle drainage system. After 20 to 30 minutes, gradually increasing suction was applied to a maximum of 25 cm H20. The intercostal tube was left in place and under suction for up to 10 days, and the presence or absence of air bubbling was recorded regularly by trained intensive care nurses. If the gas leak stopped sooner, suction was continued for 24 hours and then the tube was clamped for another day. Unless roentgenography or gas egress during a short trial of suction demonstrated persistence or recurrence of pneumothorax, the tube was removed and the patient discharged after a 24-hour observation period. In cases of treatment failure at the end of the 10-day suction period, surgical pleurectomy or tho¬ racoscopy with insufflation of talc was performed.
Statistical Methods The data were analyzed with the SYSTAT statistical system for microcomputers.9 For comparison of continuous data, the Stu-
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/28/2015
Descriptive Features of Patients* PPT, Variable No. of
First
Event
Recurrence
72
patients
SPT,
PPT,
First
PPT,
First
All
Event 20
95
23
69.6±8.9t
81.9
32.6 11.7 82.6
33.5±13.3
Gender, M/F
64/8
18/5
72/13
Side of pneumothorax, L/R
39/33 77.8
10/13 65.3
49/46
7/134
74.7
85.0*
46.6 ±89.9
41.9 ±80.9
45.6 ±87.3
99.5±120.3t
6.3±3.7
6.4±3.5
6.3 ±3.6
15.0±14.3t
Mean ± SD age, y %
