2012_Pneumothorax_AG_AAS.pdf

Acta Anaesthesiol Scand 2012; 56: 507–512 Printed in Singapore. All rights reserved © 2011 The Authors Acta Anaesthesiologica Scandinavica © 2011 The Acta Anaesthesiologica Scandinavica Foundation ACTA ANAESTHESIOLOGICA SCANDINAVICA doi: 10.1111/j.1399-6576.2011.02602.x Outcome of spontaneous and iatrogenic pneumothoraces managed with small-bore chest tubes A. Galbois1,2,3, L. Zorzi1, S. Meurisse4, S. Kernéis4, D. Margetis1,2, M. Alves1,2, H. Ait-Oufella1,2, J.-L. Baudel1, G. Offenstadt1,2,4, E. Maury1,2,4 and B. Guidet1,2,4 1 AP-HP, Hôpital Saint-Antoine, Service de Réanimation Médicale, Paris, France, 2UPMC, Univ Paris 06, Sorbonne Universités, Paris, France, INSERM, UMR_S 938, CdR Saint-Antoine, Paris, France and 4INSERM, UMR_S 707, Paris, France 3 Background: Little is known about the efficacy of management of iatrogenic pneumothoraces with small-bore chest tubes. The aim of this study was to assess the outcome of iatrogenic pneumothoraces requiring drainage managed with a small-bore chest tube and to compare the results to spontaneous pneumothoraces treated in the same unit with the same device. The primary outcome was requirement of video-assisted thoracoscopic surgery for drainage failure; secondary outcomes were length of drainage and number of inserted chest tubes. Methods: Patients with pneumothorax admitted between 1997 and 2007 were retrospectively identified. Traumatic pneumothoraces and those occurring under mechanical ventilation were excluded. All pneumothoraces were drained using the same small-bore chest tube (8 French) according to our local protocol. Results: Five hundred sixty-one pneumothoraces were analysed, 431 (76.8%) were spontaneous pneumothoraces and 130 (23.2%) were iatrogenic. Iatrogenic pneumothoraces were associated with less requirement of video-assisted thoracoscopic surgery for drainage failure [adjusted odds ratio= 0.24 (0.04, 0.86)]. Length of drainage of iatrogenic pneumothoraces was longer than for primary spontaneous pneumothoraces (3.8 ⫾ 3.1 vs. 2.7 ⫾ 1.8 days, P < 0.001) and shorter than for secondary spontaneous pneumothoraces (4.6 ⫾ 2.3 days, P = 0.004). Number of inserted chest tubes per patient was not significantly different according to pneumothoraces’ aetiology. Conclusion: Small-bore chest tubes are feasible for treatment of iatrogenic pneumothoraces and have a better rate of success and slightly longer drainage duration than when used for spontaneous pneumothoraces. neumothorax is defined as an accumulation of air or gas in the pleural space and is usually classified as spontaneous, traumatic, or iatrogenic.1 Primary spontaneous pneumothoraces occurrs in patients without evident underlying pulmonary disease whereas secondary spontaneous pneumothoraces are a complication of an underlying pulmonary disease.1 The three leading causes of iatrogenic pneumothorax are thoracentesis, subclavian venipuncture, and positive pressure ventilation.2–5 The occurrence of an iatrogenic pneumothorax has been reported to be associated with a higher hospital mortality and increased costs.3,5,6 The management of pneumothorax is influenced by its size and tolerance, by the existence of an underlying pulmonary disease and by the local protocol, which varies worldwide.3,7 The methods of treatment range from observation, simple aspiration or chest tube drainage to surgical treatment by video-assisted thoracoscopic surgery (VATS) or thoracotomy. This variability is also reported for the management of iatrogenic pneumothoraces.3 When drainage of a spontaneous pneumothorax (primary or secondary) is required, drainage with a small-bore chest tube is reported to have the same success rate, the same drain time and fewer complications than with a large-bore chest tube.8–12 Concerning iatrogenic pneumothoraces, when symptoms or size make drainage required, some authors recommend small-bore chest tubes utilisation.13,14 However, it is noticeable that these recommendations are based by extension of results observed on spontaneous pneumothoraces. Most of studies that assessed small-bore chest tube P The institution at which work was performed: Service de Réanimation Médicale, Hôpital Saint-Antoine, 184 rue du faubourg Saint-Antoine, 75571 Paris Cedex 12, France. Accepted for publication 27 October 2011 © 2011 The Authors Acta Anaesthesiologica Scandinavica © 2011 The Acta Anaesthesiologica Scandinavica Foundation 507 A. Galbois et al. utilisation focused on spontaneous pneumothoraces.9,12,15,16 Very few studies have assessed results of the iatrogenic pneumothoraces management with small-bore chest tubes. Among them, some studies included different causes of pneumothoraces and did not individualise the iatrogenic pneumothoraces outcome.17 Other studies reported less than 30 iatrogenic pneumothoraces managed with small-bore chest tubes.18–21 Moreover, no study has ever compared outcome of iatrogenic pneumothoraces and spontaneous pneumothoraces managed with smallbore chest tubes. Therefore, the current literature does not allow stating that the management of iatrogenic pneumothoraces with small-bore chest tube has similar results than for spontaneous pneumothoraces. The aim of this study was to assess the outcome of iatrogenic pneumothoraces requiring drainage managed with a small-bore chest tube and to compare the results to spontaneous pneumothoraces treated in the same unit with the same device. The primary outcome was VATS requirement for drainage failure; secondary outcomes were length of drainage and number of inserted chest tubes. Methods Study design We performed a single-centre retrospective observational cohort study in a four-bed intermediate care unit, which is part of a 14-bed medical intensive care unit (ICU). This unit houses all patients with pneumothorax requiring drainage in our 776-bed tertiary teaching hospital. Only patients with pneumothorax requiring drainage (defined as more than minimal symptoms or pneumothorax larger than 15% or ⱖ 3 cm lung collapse) are admitted to this unit. We retrospectively identified all patients with pneumothorax admitted in our unit between January 1997 and December 2007 (11 years). We did not include patients admitted after 2008 because they were included in a prospective study that evaluated pleural ultrasonography accuracy in diagnosing residual pneumothorax after chest tube insertion, which might have influenced their management.22 Patients with minimal symptoms and small pneumothoraces were treated by observation or simple aspiration alone, were not admitted to our unit and were not analysed. Population All patients with primary spontaneous, secondary spontaneous, or iatrogenic pneumothoraces 508 requiring drainage were analysed. Patients with traumatic pneumothoraces as well as patients with pneumothoraces occurring under mechanical ventilation were excluded. In both situations, the management is different from other pneumothoraces with patients treated in the ICU instead of the intermediate care unit and with larger chest tubes. Measurements The following patients’ characteristics were collected in the charts: age, gender, previous history of lung disease and Simplified Acute Physiology Score II (SAPS II).23 The following characteristics of pneumothoraces were also collected in the charts: aetiology (primary spontaneous, secondary spontaneous, iatrogenic), first episode or recurrence. The outcomes that were compared according to the pneumothoraces aetiology were: primary outcome – VATS requirement for drainage failure; secondary outcomes – length of drainage, number of inserted chest tubes, and length of stay in ICU. Drainage protocol In our unit, all the pneumothoraces requiring drainage are managed according to the same therapeutic procedure using a small-bore chest tube. All pneumothoraces were drained using the same small-bore chest tube (Pleurocath® 8 French, Plastimed® division, Prodimed®; St-Leu-la-Forêt, France) according to our local protocol. The chest tube was connected to a one-bottle water seal vacuum system regulated to generate a depression of 20 cm H2O. Every 4 h, nurses assessed chest tube patency using 5 mL of saline and noted whether bubbles were present in the aspiration device (patients were asked to cough if necessary). When chest X-ray showed complete lung expansion, the chest tube was clamped 24 h after cessation of air leak. In the absence of recurrence 6 h after clamping the chest tube, it was removed. If there was no other indication of intermediate care unit stay, the patient could be discharged 6 h after removing the pleural catheter and a last chest X-ray control. In our protocol, indications of VATS are: (1) treatment failure defined by persistent air leak 7 days after chest tube insertion; and (2) prevention of recurrences in case of second episode of ipsilateral pneumothorax, or first pneumothorax on the opposite side. In case of VATS, the patient was transferred to another hospital for surgical treatment and the length of drainage was censored. Small-bore tube for iatrogenic pneumothorax Fig. 1. Flowchart of the identified and analysed pneumothoraces. Data analysis Continuous variables were expressed as mean and standard deviation when the distribution was normal and median and interquartile interval when the distribution was not. Continuous variables were compared by the Student’s t-test. Categorical variables were expressed in numerical values (n) and percentages, and compared with the chi-squared test. Predictors of VATS requirement failure were assessed by logistic regression. Variables analysed in the univariable analysis were pneumothorax aetiology, smoking > 5 pack-years (= (Packs smoked per day) ¥ (years as a smoker)), underlying pulmonary disease and sex. All these variables were then included in the multivariate analysis, to calculate adjusted Odds Ratios. Statistical analyses were done using R 2.11.1 statistical package. Our local database was declared to the French authority (Commission nationale de l′ informatique et des libertes). According to the French regulation on research performed on data, usual informed consent was waived and replaced by information provided to patients. Results We identified 660 patients with unilateral pneumothorax during the 11 years studied. Ninety-nine pneumothoraces were excluded, 39 because of missing data, 40 because they occurred during mechanical ventilation, and 20 because of traumatic aetiology (Fig. 1). The remaining 561 pneumothoraces were analysed. Among them, 387 (69.0%) were primary spontaneous pneumothoraces, 44 (7.8%) were secondary spontaneous pneumothoraces, and 130 (23.2%) were iatrogenic (Fig. 1). Patients’ characteristics are summarised in Table 1. Patients with spontaneous primary pneumothorax were the youngest (32 ⫾ 14 year old) and had the lower SAPS II values (10 ⫾ 7). The higher SAPS II values were computed for patients with iatrogenic pneumothorax occurring after thoracentesis (40 ⫾ 19). Outcome of patients after small-bore chest tube insertion is reported in Table 2. VATS requirement for drainage failure was less frequent for iatrogenic pneumothoraces than for primary spontaneous pneumothoraces and secondary spontaneous pneumothoraces (2.3% vs. 14.0% and 12.5% respectively, P < 0.001). Assessment of odds ratio adjusted on smoking, underlying pulmonary disease, and sex showed that iatrogenic pneumothoraces were independently associated with less VATS requirement for drainage failure (Table 3). Length of drainage of iatrogenic pneumothoraces was longer than for primary spontaneous pneumothoraces (3.8 ⫾ 3.1 vs. 2.7 ⫾ 1.8 days, P < 0.001) and shorter than for secondary spontaneous pneumothoraces (4.6 ⫾ 2.3 days, P = 0.004) (Table 2). Number of inserted chest tubes per patient was not significantly different 509 A. Galbois et al. Table 1 Characteristics of patients with pneumothorax requiring drainage according to the aetiology. Spontaneous pneumothoraces (n = 431) Age, year* Male (gender), n (%) SAPS II* First episode, n (%) Smoking > 5 pack-years, n (%) Underlying pulmonary disease Iatrogenic pneumothoraces (n = 130) Primary (n = 387) Secondary (n = 44) Central venipuncture (n = 72) Thoracentesis (n = 37) Others (n = 21) 32 ⫾ 14 322 (83.2) 10 ⫾ 7 301 (77.8) 193 (49.9) 0 (0) 56 ⫾ 15 43 (97.7) 25 ⫾ 12 32 (72.7) 34 (77.3) 44 (100) 54 ⫾ 17 23 (31.9) 31 ⫾ 17 69 (95.8) 11 (15.3) 3 (4.2) 66 ⫾ 16 20 (54.1) 40 ⫾ 19 37 (100) 12 (32.4) 7 (18.9) 61 ⫾ 19 13 (61.9) 35 ⫾ 23 21 (100) 7 (33.3) 7 (33.3) *Results are expressed as mean ⫾ standard deviation. Table 2 Outcomes of patients after small-bore chest tube insertion according to the pneumothorax aetiology. Length of drainage, days Chest tube inserted, n > 1 chest tube inserted, n (%) VATS for drainage failure, n (%) Primary spontaneous pneumothorax (n = 387) Secondary spontaneous pneumothorax (n = 44) Iatrogenic pneumothorax (n = 130) 2.7 ⫾ 1.8 1.07 ⫾ 0.28 28 (7.2) 42/301 (14.0)* 4.6 ⫾ 2.3 1.32 ⫾ 0.60 11 (25.0) 4/32 (12.5)* 3.8 ⫾ 3.1 1.13 ⫾ 0.28 15 (11.5) 3 (2.3) *Pneumothoraces treated by video-assisted thoracoscopic surgery (VATS) for prevention of recurrences in case of second episode of ipsilateral pneumothorax, or first pneumothorax on the opposite side were excluded (n = 86 primary spontaneous pneumothorax, n = 12 secondary spontaneous pneumothorax). Table 3 Crude and adjusted odds ratio (OR) for video-assisted thoracoscopic surgery requirement because of drainage failure. Variables Crude OR (95% CI) Adjusted OR (95% CI) Pneumothorax aetiology: Primary spontaneous Secondary spontaneous Iatrogenic Smoking > 5 pack-years Underlying pulmonary disease Male (gender) 1 0.70 0.15 1.66 0.94 3.16 1 0.91 0.24 1.05 0.75 1.60 (0.19, (0.03, (0.64, (0.26, (1.02, 2.18) 0.49) 4.31) 2.71) 13.87) (0.06, (0.04, (0.38, (0.00, (0.46, •) 0.86) 3.02) 9.02) 8.50) CI, confidence interval. according to pneumothoraces’ aetiology (Table 2). In the three cases of iatrogenic pneumothoraces with VATS requirement for drainage failure, the air leak persisted despite a full lung expansion. Iatrogenic pneumothoraces secondary to central venipuncture or thoracentesis have both the same mechanism: the parietal pleura is perforated by a needle. Their outcome was compared and no difference was found regarding the requirement of VATS for drainage failure, the length of drainage, and the number of chest tubes inserted. Discussion This study is the greatest reported cohort of iatrogenic pneumothoraces managed with small-bore 510 chest tubes and the first study to assess their outcome comparing the results to spontaneous pneumothoraces managed with the same device. Our main result is that the management of iatrogenic pneumothoraces with small-bore chest tubes has very good results with extremely rare treatment failure requiring VATS (2.3%). The iatrogenic aetiology is independently associated with a decreased requirement of VATS (adjusted OR = 0.24 (0.04, 0.86). The comparison between iatrogenic pneumothoraces and spontaneous pneumothoraces was performed because, when chest tube insertion is considered for spontaneous pneumothoraces, small-bore chest tubes are now largely recommended.1,24,25 As there is no previously published Small-bore tube for iatrogenic pneumothorax large cohort of iatrogenic pneumothoraces managed with small-bore chest tubes, the fact that we report a lower failure rate in iatrogenic pneumothoraces than in spontaneous pneumothoraces is a major argument to prefer small-bore chest tubes in iatrogenic pneumothoraces as well. A potential explanation to this lower failure rate, whereas iatrogenic and spontaneous pneumothoraces were managed in the same way, could be that the causes of spontaneous pneumothoraces (blebs or bullae) still remain after the drainage whereas in iatrogenic ones causes have immediately stopped after occurrence. In our unit, application of suction on the smallbore chest tube is part of the routine management of pneumothoraces. Whereas suction has been reported to facilitate persistent air leak in patients after VATS26–28, there is no consensus about the application of suction during management of pneumothoraces with small-bore chest tubes.24 Routine application of suction (with a pressure of 20 cm of water) has not been shown to improve the outcome in spontaneous pneumothoraces.29 It is noticeable that Laronga et al. have reported a 15% failure rate using small-bore pigtail chest tubes and Heimlich valves to treat 34 iatrogenic pneumothoraces complicating central venous catheter insertion.21 The present study does not allow conclusions concerning whether the aspiration device used in our unit has contributed to our low failure rate. The only tested outcome that was less in support of using small-bore chest tubes to treat iatrogenic pneumothoraces was a more prolonged length of drainage than for primary spontaneous pneumothoraces. However, this length of drainage is still less than 4 days, which is quite reasonable and is in accordance with previous published studies.2,3,30 These results should promote the utilisation of small-bore chest tubes to treat iatrogenic pneumothoraces with an excellent rate of success. Our study suffers from several limitations. First, this is a single centre study. However, we consider that it is one of the strengths of our study because all pneumothoraces were managed similarly except for the pneumothoraces occurring during mechanical ventilation, which were excluded from the analysis. Accordingly, our results are not applicable in this subset of patients. Second, duration of drainage was censored among patients referred to surgery. All of them effectively underwent VATS after a delay between 0 and 3 days, depending of the operative room availability. We have chosen to censure duration of drainage because we did not want that the operative room availability could introduce bias. Finally, we showed that using small-bore chest tubes to treat iatrogenic pneumothoraces has very good results but the design of this study doesn’t allow concluding that small-bore chest tubes have better results than large-bore chest-tubes. The only way to conclude would be to perform a randomised study. However, using small-bore chest tubes is associated with fewer complications than large-bore chest tubes8,9,14 and the results of the present study promote their utilisation in iatrogenic pneumothoraces requiring drainage. Conclusions In conclusion, this study demonstrates that the utilisation of small-bore chest tubes to treat iatrogenic pneumothoraces has a better rate of success and slightly longer drainage duration than for spontaneous pneumothoraces. These results plead for small-bore chest tubes utilisation for iatrogenic pneumothoraces requiring drainage. Acknowledgements None. Conflict of interest or research support: none. References 1. Sahn SA, Heffner JE. Spontaneous pneumothorax. N Engl J Med 2000; 342: 868–74. 2. Sassoon CS, Light RW, O’Hara VS, Moritz TE. Iatrogenic pneumothorax: etiology and morbidity. Results of a department of veterans affairs cooperative study. Respiration 1992; 59: 215–20. 3. Despars JA, Sassoon CS, Light RW. Significance of iatrogenic pneumothoraces. Chest 1994; 105: 1147–50. 4. Chen KY, Jerng JS, Liao WY, Ding LW, Kuo LC, Wang JY, Yang PC. Pneumothorax in the ICU: patient outcomes and prognostic factors. 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