A young, tall, athletic man is brought to your emergency department by ambulance after he experiences sudden-onset shortness of breath. He’s tachypneic but not has otherwise normal vital signs upon examination. You’re not sure if you hear breath sounds on one side. Being the ultrasound enthusiast that you are, you grab the probe and note a conspicuous lack of lung sliding. The diagnosis of pneumothorax is confirmed immediately thereafter by chest x-ray.

Let’s talk chest tubes! This gentleman is obviously in need of some intervention to help with re-expansion of his lung. Shall we reach for the traditional, large-bore chest tube? Or is there another way?

Suck it out.

In fact, data suggests that simple manual aspiration is as effective at resolving a spontaneous pneumothorax as a traditional chest tube under the right circumstances, It is actually recommended (level A) by the British Thoracic Society (BTS) as first-line therapy for first-episode spontaneous pneumothorax as long as the patient is hemodynamically stable, the pneumothorax is 20-40% of lung volume, no more than 4L of air is removed, and there’s no tension.[1],[2] That being said, the data here is exceptionally scarce – a Cochrane review from 2007 was only able to find 6 studies comparing manual aspiration to thoracostomy and determined that only 1 study was satisfactory. It did conclude (based on the one study) that aspiration has similar rates of success and eventual progression to surgery and decreases the need for admission, length of stay, and recurrence rates when compared to chest tubes.[3] Our own Dr. Zehtabchi performed a systematic literature review, and based on 3 RCTs, came to similar conclusions: Aspiration decreased the need for hospitalization and need for analgesia.[4] Small RCTs (one including 56 patients and one including 60 patients) do back this conclusion,[5], [6] and it makes sense logically – a patient with a tube hanging out of their chest wall is more likely to experience painless and less likely to be sent home than someone without it.

A quick how-to

I borrowed these excellent instructions (below) and illustrative pictures (above) from Repanshek et al.2 NEJM also has an illustrative video on the procedure here.

Back to the patient

Following the BTS guidelines, you decide to perform a needle aspiration by which you remove approximately 3L of air. The patient is symptomatically improved and symptoms do not recur during a 4-hour observation period. A repeat radiograph confirms lung expansion, and the patient is deemed reliable with good follow-up, so you discharge him home with instructions for re-evaluation in 24 hours.

But what if it’s traumatic?

OK, so you can potentially use needle aspiration for a spontaneous pneumothorax. But what if your patient has just been smacked by a bus? What if there’s the potential for blood in the chest instead of just air? There’s no large, well-designed trials on needle aspiration for traumatic pneumothoraces or hemothoraces, but there is talk of potentially using small-bore, 14 french (Fr) pigtail catheters in lieu of the larger, 28-40 Fr chest tubes traditionally placed. One of the main selling points is that smaller tubes are less painful for the patient when inserted.[7] The data is, again, less-than-robust here – 2 retrospective studies demonstrated that pigtail catheters placed for traumatic pneumothorax were as effective as traditional chest tubes at lung re-expansion without complications and were associated with a shorter duration of stay.[8],[9] The caveat here is that pigtails were typically placed in patients that had lower injury severity scores and later in the course, suggesting the patients were potentially not as sick. In terms of drainage for hemothorax, data is even sparser. One study of 227 patients in whom either chest tubes or pigtail catheters were placed for hemothorax concluded that pigtails had similar initial rates of blood output as well as length of stay, duration of tube dwell time, failure rate, complications, and mortality.[10] In this trial, pigtails were more likely to be placed for blunt rather than penetrating trauma, and again, pigtails were placed later in the course. This data is flawed and difficult to interpret due to inherent biases, but it does at least suggest that in a pinch, a smaller tube may be as effective as the 40 Fr pipe that the trauma team is likely going to want to place.

Conclusion, please

Manual aspiration seems to be effective in treating spontaneous pneumothorax. It is also less painful for patients and may decrease hospital length of stay and/or the need for admission in the first place (more on discharging pneumothoraces from the ED later – stay tuned). For traumatic pneumothorax and hemothorax, large-bore chest tubes are probably still the way to go (at least until there’s better data out there) unless you’re feeling particularly gutsy. Thanks again to Dr. deSouza and Shibata for their editing.

[1] Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010.

MacDuff A, Arnold A, Harvey J; BTS Pleural Disease Guideline Group. Thorax. 2010 Aug;65 Suppl 2:ii18-31. doi: 10.1136/thx.2010.136986.

[2] Alternative treatments of pneumothorax. Repanshek ZD, Ufberg JW, Vilke GM, Chan TC, Harrigan RA. J Emerg Med. 2013 Feb;44(2):457-66. doi: 10.1016/j.jemermed.2012.02.049. Epub 2012 May 22.

[3] Simple aspiration versus intercostal tube drainage for primary spontaneous pneumothorax in adults.

Wakai A, O’Sullivan RG, McCabe G. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD004479.

[4] Management of emergency department patients with primary spontaneous pneumothorax: needle aspiration or tube thoracostomy? Zehtabchi S, Rios CL. Ann Emerg Med. 2008 Jan;51(1):91-100, 100.e1. doi: 10.1016/j.annemergmed.2007.06.009. Epub 2007 Sep 29.

[5] A prospective, randomised trial of pneumothorax therapy: manual aspiration versus conventional chest tube drainage. Parlak M, Uil SM, van den Berg JW. Respir Med. 2012 Nov;106(11):1600-5. doi: 10.1016/j.rmed.2012.08.005. Epub 2012 Aug 24.

[6] Manual aspiration versus chest tube drainage in first episodes of primary spontaneous pneumothorax: a multicenter, prospective, randomized pilot study. Noppen M, Alexander P, Driesen P, Slabbynck H, Verstraeten A. Am J Respir Crit Care Med. 2002 May 1;165(9):1240-4.

[7] Randomized clinical trial of pigtail catheter versus chest tube in injured patients with uncomplicated traumatic pneumothorax. Kulvatunyou N, Erickson L, Vijayasekaran A, Gries L, Joseph B, Friese RF, O’Keeffe T, Tang AL, Wynne JL, Rhee P. Br J Surg. 2014 Jan;101(2):17-22. doi: 10.1002/bjs.9377.

[8] Small catheter tube thoracostomy: effective in managing chest trauma in stable patients. Rivera L, O’Reilly EB, Sise MJ, Norton VC, Sise CB, Sack DI, Swanson SM, Iman RB, Paci GM, Antevil JL. J Trauma. 2009 Feb;66(2):393-9. doi: 10.1097/TA.0b013e318173f81e.

[9] Two-year experience of using pigtail catheters to treat traumatic pneumothorax: a changing trend. Kulvatunyou N, Vijayasekaran A, Hansen A, Wynne JL, O’Keeffe T, Friese RS, Joseph B, Tang A, Rhee P. J Trauma. 2011 Nov;71(5):1104-7; discussion 1107. doi: 10.1097/TA.0b013e31822dd130.

[10] 14 French pigtail catheters placed by surgeons to drain blood on trauma patients: is 14-Fr too small?

Kulvatunyou N, Joseph B, Friese RS, Green D, Gries L, O’Keeffe T, Tang AL, Wynne JL, Rhee P. J Trauma Acute Care Surg. 2012 Dec;73(6):1423-7. doi: 10.1097/TA.0b013e318271c1c7.

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