QJM Advance Access originally published online on June 29, 2006
QJM 2006 99(7):489-491; doi:10.1093/qjmed/hcl067
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Correspondence |
Pigtail catheter drainage for secondary spontaneous pneumothorax
Sir,Several treatments are recommended for a first episode of primary spontaneous pneumothorax (PSP), including simple observation, oxygen supplementation, simple aspiration and chest tube drainage, depending on the severity of pneumothoraces. 1 However, management for secondary spontaneous pneumothorax (SSP) remains problematic, because of the lack of universally accepted management guidelines. Previously, we reported our experience in treating PSP using pigtail tube drainage and the results were promising.2 However, it is still not known whether the pigtail catheter is effective in the management of SSP. We now report our experience and results using the pigtail catheter in the treatment of SSP over a 3-year period.
From July 2002 to July 2005, 64 patients with a first episode of SSP treated at the China Medical University Hospital were included in our series: 52 males (81%) and 12 females (19%). The age range was 17–91 years, mean ± SD 59.5 ± 19.0. A chest ultrasound examination was performed first for guidance; then the pigtail catheter (10 to 14 Fr) with a trocar system was inserted into the superior part of the fourth to six intercostal space at the middle axillary line, after local anaesthesia. After the procedure, the catheter was connected to a Heimlich one-way valve drainage bag. Patients were closely followed-up with a chest X-ray (CXR) immediately after the procedure and at 24 h, 48 h and later as necessary. When there was no more air drainage from the one-way valve drainage system, and the lung had reached full expansion, as revealed by CXR, the pigtail was extubated. Patients were discharged when there were no more clinical symptoms and/or no air accumulated in the pleural space on follow-up CXR.
Among the enrolled 64 patients with SSP, COPD was the most common underlying disease, accounting for 56% ( Table 1). Clinically, 46 patients (72%) were successfully treated with pigtail catheter drainage, the remaining 18 (28%) needing further management. Also shown in Figure 1, in the 18 patients with further treatment, nine patients received large-bore chest tube drainage, eight subsequently underwent thoracoscopy with pleurodesis, and the remaining one later died from complications of his underlying disease.
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The patients with SSP successfully treated by pigtail catheter drainage (n = 46) and those who were not (n = 18), were not significantly different with respect to gender, age, pneumothorax size (Light index), affected side, initial symptoms, vital signs before tube insertion, underlying diseases, or smoking status. Only body weight and body mass index (BMI) were significantly different between the two groups (p < 0.05). Unsurprisingly, those successfully treated with the pigtail catheter had a shorter duration of hospital stay than those failing treatment (13.3 ± 18.4 vs. 29.4 ± 24.1, p < 0.05). Nevertheless, recurrence rates (15% vs. 17%) at 6-month follow-up and the time of recurrence (52.1 ± 35.8 vs. 22.3 ± 3.8 days) after discharge were not significantly different. No major complications occurred in any patiens receiving pigtail catheter, large-bore chest tube or surgical treatment.
The British Thoracic Society has published guidelines recommending observation alone or simple aspiration for treating minimal, asymptomatic SSP, and performing intercostal tube drainage for large pneumothoraces initially. 3 However, Baumann suggested that simple aspiration is probably inappropriate for most SSP episodes, because of the greater need for recurrence prevention and the potential for persisting air leaks.4 We are unaware of any other studies of small-bore chest tube (pigtail) drainage as initial treatment in patients presenting with a first episode of SSP. Our overall success rates in SSP patients treated with pigtail catheter drainage (72%) was however similar to that in previous reports treating SSP with large-bore chest tube drainage.2,5
Nevertheless, 18 patients (28%) were not successfully treated with pigtail catheter drainage, and five of these were subsequently successfully treated using large-bore chest tube drainage. A means of identifying patients in whom large-bore chest tube drainage is more likely to be successful as their initial management would therefore be useful. In our series, body weight and BMI were both lower in patients who were successfully treated with the pigtail catheter than in those who were not (p < 0.05). Increased BMI can lead to decreased functional residual capacity, compliance of the total respiratory system and oxygenation index (PaO2/PAO2), and to increased resistance in the respiratory system and work of breathing. Whether these factors affect the success rate of catheter or tube drainage for SSP deserves future study.
Our series has limitations. First, this was a retrospective study; initial selection for tube drainage for SSP may affect the results and the success rates. Second, number of enrolled patients was small, and consequently we could not further analyse possible factors in treatment failure. A large, prospective, randomized trial would be needed to confirm our results.
China Medical University Hospital
Taichung
Taiwan ROC
email: hsuwh{at}www.cmuh.org.tw
References
1. Baumann MH, Strange C, Heffner JE, Light R, Kirby TJ, Klein J, Luketich JD, Panacek EA, Sahn SA. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi Consensus Statement. Chest 2001; 119:590–602.
2. Liu CM, Hang LW, Chen WK, Hsia TC, Hsu WH. Pigtail tube drainage in the treatment of spontaneous pneumothorax. Am J Emerg Med 2003; 21:241–4.[CrossRef][Web of Science][Medline]
3. Heary M, Arnold T, Harvey J. BTS guidelines for the management of spontaneous pneumothorax. Thorax 2003; 58:39–52.
4. Baumann MH. Treatment of spontaneous pneumothorax. Curr Opin Pulmon Medicine 2000; 6:275–80.[CrossRef]
5. Baumann MH and Strange C. Treatment of spontaneous pneumothorax. A more aggressive approach? Chest 1997; 112:789–804.
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