Update Course Rewind: Spontaneous Pneumothorax 2021

So, did you miss our annual pediatric surgery update course? Well, don't worry, because we're gonna summarize it for you right here on this podcast. I'm Rod. And I'm Ellen and Cisco. We're research residents at Cincinnati Children's Hospital Medical Center. And this is the Stay Current in Pediatric Surgery Podcast. The treatment for spontaneous pneumothorax is a moving target lately. A lot of new literature has come out that is in support of conservative management. But what exactly is conservative management? And when do you pull the trigger on a VATS? Well, today we're going to talk about pneumothorax with an expert. There there is a lot of data in in both adults and pediatric patients. That's Ronnie Sollons. Wait, wait, wait, Ronnie Sollons? The former soccer player for the Women's US National Team? Yes. She was an Olympic soccer player, but now she's Dr. Sollons, pediatric surgeon at UCLA Mattel Children's Hospital. All right, let's start with the case. So this patient came in with chest pain and got the imaging that you see here. And you'll also notice the positive radiology sign. On presentation, he's hemodynamically stable. Again, just has that chest pain. So what do you want to do? Before you answer, Dr. Sollons wanted to show us just how far we've come in treating spontaneous pneumothorax. Let's look back at an even older update course from seven years ago. Was anybody anybody considered this last algorithm, simple aspiration? No, so, well, the two purposes, I guess, number one, by having the lung apposed to the chest wall, it may seal faster or number two, to get rid of the symptoms, otherwise why not just leave it alone. If you're gonna aspirate it, I don't know if you're gonna use a needle or not where you might stick the lung. If you have an apical pneumothorax though is small like you originally had, and you put a needle in, you'll have a bigger pneumothorax. Yeah, yeah, yeah, absolutely. So and if you got a little one, just leave him alone. And just to be clear, and just to be clear, Ronnie, it was the same people that are in this room today that were very vocal about how crazy that would be. Right. Now, keep in mind, this was a live event. So when we ask what everyone would do, that was a poll question with a lot of really interesting responses. But our boss, Todd Ponsky, had some interesting things to say about that. Wait, so can we just can just explain the word needle? For a quote large large enough pneumothorax, uh, to put a needle, um, anteriorly in the second or third intercostal space and just suctioning it out. You attach it to a, uh, a three way stopcock and then you you suction it out. You can use, um, like a vascat as well or an angiocat. If you can use an angiocat, can you just put in a little pigtail? Right. So that's actually what some people do to also aspirate. I mean aspiration can be with a needle or with less than 12 French pigtail catheter, which a lot of the studies have uh intervention is essentially uh one of the two things you tube thoracostomy through a catheter that's less than 12, um, or just aspiration and observe. So when you look at these options, some of them are more conservative than others, but it kind of begs the question. I mean, how does the literature even define conservative management for a spontaneous pneumothorax? Dr. Arca had mentioned that what she considered conservative management was actually tube thoracostomy, whereas a lot of the studies now are talking about concer conservative management is just observation with oxygen, pain management, and really not doing anything invasive, including needle aspiration or tube thoracostomy. All right, let's dive into the research. Dr. Sollons is going to summarize a recent study from the Midwest pediatric surgery consortium. And don't worry, as usual, we'll put the link down below so that you can read the whole article for yourself. Last year the Midwest Consortium did a multicenter prospective study. They enrolled 33 kids with a first presentation of spontaneous pneumothorax and essentially was aspirated through a pigtail catheter that's less than or equal to a 12 French. They had a six hour observation with the tube clamped. And then if there was a recurrent or or or enlarging pneumothorax, um, then it was managed per surgeon preference. So they found that 48% were successfully managed with just the aspiration and the rest failed. And then in those who failed, recurrence was 83%. Of the group that was successfully managed with aspiration, 44% recurred. And the failure of chest tube and VATs subsequent VATs were essentially consistent with the published rates of recurrence and complications. So what do they conclude? They propose changing the algorithm to proceed directly to VATs if the initial aspiration fails. I'm coming in being a part of that study and it it was surgeon preference. That's Dr. Sean St. Peter. He's the surgeon in chief at Children's Mercy Kansas City. But what we decided uh at Mercy was that we weren't we weren't gonna do that because of what you just said, that if we move to putting in the chest tube, then it's leads to kicking the can down the road. So the chest tube goes in on a Thursday. You're not gonna do anything. The weekend person might say, well, let's wait and put it on suction for two days and see if it's better by Monday and people end up staying five or six days in the hospital. So we said, if if it's anything short of perfect, if the aspiration doesn't work, we're going straight to VATs that day. So that way we can turn them all into a max two or three hospital day stay instead of having some that linger out for four, five, six days while you go back and forth between water seal and suction while you're you're changing who's who's running the service. So the MWPSC study suggests that maybe we should go from aspiration to VATs in these patients who present with spontaneous pneumothorax. Now, here's another study from our friends over in Australia and New Zealand. And you guessed it. It's linked below. So scroll down under the media player and open it up. Um, it's from Australia, New Zealand. It was a multi-center non-inferiority trial. Patients were randomized. So this is actually adult patients as well. So patients were 14 to 50 years old. They enrolled 316 patients, looked at moderate to large pneumothoraces. So this is like a about a 32% collapse. This isn't like a tiny pneumothorax. And what they were trying to ask was whether or not, um, you could you could observe, um, moderate to large pneumothoracies. The success rate in the intervention group was 98.5% versus 94.4% in the observation group. Plus in the observation group, they actually had lower rates of both adverse events and one year recurrence. So basically this is saying that even patients with seemingly large spontaneous pneumothoracies can be managed with observation alone. We think of moderate to large pneumothoracies as something that need intervention, but to the point, um, if you rupture a bleb and then it doesn't continue to leak, maybe it scars down and then you don't ever have to do anything going back to uh Steve Lee's uh patient earlier. What do you guys think? I you know, I treat this like an epigastric hernia. I I have the discussion with the families. I don't have a definitive way. Few things I do different. Ellen and I had this case over the weekend and we talked a lot about your studies. First of all, a needle scares me because as soon as it expands, you're gonna poke a hole in it. So if anything do a uh an angiocath. I put in a pigtail and leave it in instead of uh angiocath. I can be convinced otherwise. So I'm not ad adamant about that. That's just what I do, but I aspirate, clamp and do the x-ray. Also, I've never seen a patient in extremis from a spontaneous pneumothorax. I know that I brought this up before and others disagree with me, but I have never seen that. And so it's a different disease than a traumatic pneumothorax. The the 44%, I would expect a lot more patients would say, just do it, but they don't. I mean, it seems like they say, yeah, you know what? I'll take my chances because the chances of a problem from a spontaneous pneumothorax is low. You'll get some discomfort and we'll do it later. So if it's someone that's overseas or in a tough place, then I would do it. So there you have it. The session on spontaneous pneumothorax from our 2021 pediatric surgery update course. So make sure you follow us on social media. Like and subscribe to our YouTube channel. And if you're listening on a podcast player, go ahead and give us a review, leave a comment, let us know what you want to hear about. But until then, I'm Ellen in Cisco. I'm Rod from Cincinnati Children's. And remember, knowledge should be free. Knowledge should be free.