Update Course 2021: PNEUMOTHORAX

In the interest of time, I'd really like this to be more of a, um, you know, a discussion with everybody because I think that there are, uh, there are a lot of things to talk about with spontaneous pneumothorax. Um, I think are my slides up yet? Let's see. Um, and I think there's a little bit of, there there is a lot of data in in both adults and pediatric patients. But I want to pose this question first. So, uh I hope you all can see this. I put little uh my radiology hat on and put some arrows on this for uh spontaneous pneumothorax. So, um the, the question, let me see if I can get this thing. Okay, so how would you manage this uh patient? Um, and I'll start by saying that the, that the patient came in with pain and, uh, and, um is is hemodynamically stable. So this is our poll question. Um, and while we're thinking about this, I just want to do a little, I want to show you a little blast from the past about seven years ago, um, Dan Austley in the Global Cast uh 2014 update course, um took us through a review of spontaneous pneumothorax. And, um, and I just, um, let's see, it's pretty short. But here is, let's see if I can get this to work. Can you guys hear? This has audio, guys. So let's see if we can get this. This is pretty funny. Yeah. 2014 update. Oh wow. Uh. Bummer. No. Hey uh Garrett, is there any way we can get audio on that video? Do you know? Well, why don't you tell us what what what was said in that because it was pretty funny. So, Dan Austley is asking, this is the same question, uh, slightly different answers and everybody, uh, you know, he asked, okay, so these are the choices. What do you, what do you guys think about simple aspiration? And and just about everybody said, oh no, I wouldn't do that. And then somebody uh used an expletive somewhere in there. I wouldn't deal with that pile of something, uh, and then, uh, and then said, why would you do that? And it was it was very much like, you know, why why are you doing? And this is from, so this is from 2014. Um, and keep in mind by the way that the uh British thoracic Society has been advocating for aspiration since 2003, which is also an interesting um point to make. But um, it's too bad that you can't hear it because it's uh it's actually it's pretty hilarious. Um, and if in case you want, um, I'm going to put the, I'll put a link to it in the chat so that you can actually see it's a 16 minute review, uh, and you can take a look at it. It's pretty um, it's pretty interesting. 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. And, and one of us has a lot longer hair, um, Todd Ponsky, uh, and uh, and everybody's sitting in sort of oversized suits and talking about this uh bantering a little bit. So, um, so I let's, can we go to the poll and just see what uh people said? Sure. Yeah, it looks like um a third, about a third are saying needle aspiration. Um, about 40% are saying observation with supplemental oxygen and then 20% are saying tube throacostomy. Wait, so can we just can just explain the word needle? That's that's the question I have a problem with. Yeah, so needle, uh, essentially, you know, 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 stop cock and then you you suctioned it out. You can use um like a vast cath as well or an angiocath uh and So if you can use an angiocath. If you can use an angiocath, 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 uh with a little um less than 12 French pigtail catheter, which is uh which is a lot of the studies have uh intervention is essentially uh one of the two things. You tube throacostomy through a catheter that's less than 12, um or just aspiration and observe. So, so that's still considered uh, you know, we were talking about before with um Dr. Arcan had mentioned that what she considered conservative management was actually tube throacostomy, whereas a lot of the studies now are talking about consert conservative management is just observation with oxygen, pain management and really not doing anything invasive including needle aspiration or tube throacostomy. Um, so I just want to go over a couple of recent, um, uh, of recent studies. Um, last year the Midwest Consortium did a multicenter prospective study, uh, and um, they enrolled 33 kids with a first presentation spontaneous pneumothorax and um, 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. If a second aspiration was necessary, it was allowed if if they didn't see reexpansion on the immediate X-ray. Um, but uh, but essentially after aspiration through this pigtail catheter, six hour observation with the tube clamped and um, and then if there was a recurrent or enlarging pneumothorax, um, then it was managed per surgeon preference. Um, uh 48% were successfully managed, um, uh with just this aspiration alone and 52% failed. And then in those who failed, recurrence was 83% versus 44% in those who passed this first aspiration test. Um, there weren't any procedural complications and um, and the failure of chest tube and VAT subsequent VAT were essentially consistent with the published rates um of uh of recurrence and complications. So they they proposed changing the algorithm to proceed directly to VAT if the initial aspiration fails. And so I I I'm wondering what people think of this because a lot of times there's a step-wise approach saying, okay, well, even if even if you don't aspirate but you put a tube in and you try to get it out and then you sit on, sit on water seal or suction for three to five days and then you decide, oh, well maybe let's see if I could should take them to surgery. Whereas, you know, if if so many of them fail anyway after chest tube placement, then why not just go to Vats. I'm curious to hear what people think. I'll chime in being a part of that study and it it was surgeon preference, but what we decided uh at Mercy was that we weren't, we weren't going to do that because of what you just said, that if we moved to putting in the chest tube, then it leads to kicking the can down the road. So if the chest tube goes in on a Thursday, you're not going to 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 could turn them all into a max two or three hospital they 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. And we don't have that data mature yet, but um, we we've liked that approach. And in light of this new randomized trial, um that you're going to talk about, I think it's perfectly reasonable as Steve alluded to with his patient is to just repeat a chest x-ray because like we talked about last year, the real discernment is whether you're treating somebody who has a leak or somebody who had a leak. And so if they popped a bleb and now they've got a pneumo, as long as they're not too terribly symptomatic, that doesn't mean much of anything. What you're trying to do with the aspiration test and what you're trying to do with the observation and repeat image is, did they rupture a bleb and are still leaking? In which case they may need treatment. Right. So, um, excellent comments. I think in the interest of time because we're running a little bit late, I will talk about that study. Um, let's see, can we grab my slides up. So the second study is was also from 2020 and um was published in the New England Journal of Medicine. Um, it's from Australia, New Zealand. It was a multicenter non-inferiority um uh trial. Um, patients were randomized. So this is actually adult patients as well. So patients were 14 to 50 years old. Um, they enrolled um, they enrolled 316 patients and this was actually a non-inferiority trial where they looked at moderate to large pneumothoracies. 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. Uh, so um they put a for the intervention group, they put a less than or equal to 12 French chest tube in place. Uh, they placed it to water seal, got a chest x-ray an hour later and then um if there was no air leak and it's re-expanded, then they would clamp the chest tube for four hours and then repeat the X-ray and then send them home if they're asymptomatic. Um, the uh um uh sorry, that yeah, that was the interventional. And then the conservative management was just at least a four hour observation and then they repeat the chest X-ray and if they're a symptomatic, sorry if they're asymptomatic, they they go home. And then if they actually have symptoms, if they're hemodynamically unstable, if they still have pain, if they can't walk around without oxygen, uh, then they have intervention per surgeon management. So, um, so the they were reassessed between 24 and 72 hours and then two, four and eight weeks uh with um with a face-to-face interaction and a chest x-ray. Um, so in the just to cut to the chase, in the in the intervention group, um, so about um, uh um 84.6% of patients uh in the observation group didn't have any interventions, whereas 15.4% did have interventions. Um, and they they had so they had uh there were no there's no difference in reexpansion um and oh I have to go to the hold on. I don't know how this popped over. There we go. So, um, so managed successfully in as you can see here, 98.5% in the intervention group versus 94.4% in the observation group. There's no difference in this. My this thing is going a little bit crazy. Uh, hold on. I don't know why. Can we go back to I'm so can we go back to the um one with the there, right there. Um, so there was uh no difference in reexpansion, uh the median time to reexpansion was 16 days for the intervention group versus 30 days, but the median time to symptom uh uh symptom uh resolution was about the same. Um, and then the recurrences in the first 12 months in the observation group was 8.8% uh versus 16.8% in the um in the intervention group. So, um and the time to reoccurrence is was also longer in the observation group. So, um they had the observation group had fewer days of chest tubes, fewer CT scans, fewer hospital revisits, fewer adverse events and serious adverse events, fewer chest x-rays and hospital days in the first eight weeks. So I uh I just want to sort of talk about this as, you know, 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? Can I just say something? I know these articles are discussing conservative versus intervention, which I understand is drain, not necessarily surgery. And both seem to be very equivalent, but the recurrence rates for both groups seems to be really, really high. I I mean if we were talking about, I don't know, maybe 5% versus the 80%, um, what I'm trying to say is that maybe there's an opportunity for surgical management for both. No, as as as an initial treatment for the pneumothorax. I think observation and chest drain look pretty the same in these articles, but there is a chance to offer surgical treatment like, I mean, definitive surgical treatment to both of these groups, not to offer them, not not necessarily do them all, but with a 44% recurrence rate, I think it's something sensitive to talk to the families, isn't it? Oh, absolutely. I mean, I think that we can accept that there is a high recurrence rate, but I mean, primary VAT also has a recurrence rate of 15%. So if you offer, if you offer primary VAT right off the bat to people, then you're actually doing surgery on people who may not necessarily need it. I don't know, what do people, what do people think here? Because this is um I think that I would echo, I would echo what you just said, Ronnie, um, and that 44%, you can look at it the other way. Even if that's a high recurrence rate, you're performing an operation in 56% of patients who may not need it, and that in itself has associated complications. Now, I'm old in many aspects and new in many aspects in that it seems like we're trying to do non-operative management for everything, which I've kind of jumped on for appendicitis, for this and that. But but um, you know, the initial management, I still think the less you do the better and if they recur and need an operative uh intervention then I wouldn't hesitate to to offer them that. But I I do worry about offering surgery to everybody up front. And then you know, having a complication and finding out half the patients didn't actually need that operation. 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. Alan and I had this case over the weekend and we talked a lot about your studies. Um, number one, uh, first of all, a needle scares me because as soon as it expands, you're going to poke a hole in it. So if anything do a uh an angiocath. I put in a pigtail, um, and leave it in instead of uh angiocath. I can be convinced otherwise. So I'm not adamant about that. That's just what I do, but I aspirate clamp and do the X-ray. Also, I have 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. Um, and so it's a different disease than a traumatic pneumothorax. Um, 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. Um, I also don't do um any uhsis because of the studies that have shown you don't need to. Uh, there's a lot of other things. I think Ronnie this deserves its own entire thing. I know we're like 10 minutes over, but what other final comments do other people have? And while you guys are thinking about this, I'm just going to go for just if you show the last slide. I just want to put in a plug for the Absent Education uh committee because they they created this awesome visual abstract and I'm going to skip this meta analysis because it basically supports the same thing. Um, but uh, but so this is the visual abstract and essentially looking at what the take home points are, um, and you can find it on pedsurge library.com, which is an awesome resource as well. Um, but I wanted to just move forward because you brought this up. Uh, there were a couple things that we I felt like we could discuss. Number one, do you CT scan to look at the other side and then do you dosis or not? Okay, so Ronnie and Sean can run this. This is what we do when we're out of time and you put that something like that up on the screen. This gets fun. We're going not I need that slide back up. Hold on. So, uh, we're going to do rapid fire. You got no discussion here. You just get no more than a sentence. So uh Sean, do you get cat scans? No. Okay, uh Jose cat scans. We'll we'll keep going for until your mic is unmuted. Steven Lee, cat scan? No. Eh I said yes, sorry. Yes, you get a cat scan. Bethany. No. Dan. No. Okay. Mark. How about this? Does anyone other than Jose get cat scans? Okay, we're going to move on. The one sentence on that, we looked at that data and we found that the presence or absence of a bleb didn't correlate with the presence or absence of them coming back to seek care for a pneumo on that side. So you get blebs and you don't come back, you don't have blebs and you come back. opinion? No, you don't get to defend your opinion. We got no time. Put it in the chat. Plus. Who does plus? I do. Who Okay, anyone here does not dosis other than me. I don't. I dosis but looking at the literature after this review course, I may actually not do it uh just because there are, there are studies that show it doesn't make a difference at all and it just causes more pain. And actually I'll do it like an apictomy which hurts. So. I'll give you the data. Any other comments on this? Uh Jose, if you can do it in one sentence, tell us your argument on why you get cat scans. Uh not for the ipsilateral side, but if the family is looking for a bilateral surgery, I would stratify the other side with a CT scan. Okay, so no ships. can make a difference. No bleps zero recurrence. Uh bleps on the other side is 20% recurrence. That's it. Okay. All right. Uh multiple recurrent pneumothorax. What do you want to Oh no, apical pneumothorax post up. What do you want? Oh, doesn't everybody get an apical pneumothorax post up? It's like 100%, right? Do you do anything about it? No, I say you got an apical pneumo. What other? Anyone do anything different? Tell them they can't fly on an airplane. I mean, seriously, I think it's almost 100% for me because that space you took out volume. You remove a a piece of lung. Yeah. Of course. Yeah, it'll take a while, you know? Take a while. Yeah. If you don't see, if you don't see a space, you didn't get the bleb. Okay, so You messed up. You messed up. All right. Ronnie, what's your last one there? The multiple recurrent pneumothoraces. Um, these are challenging patients, often have complications, prolonged hospital stays, prolonged chest tubes. Uh what do you do with these patients? Do you use Talk? I refer to Posky. Talk. Talk them up. This is the question, you know, people are afraid if you talk then you can't ever operate on that lung again. But you got to decide, you want it to stick or not. What? You won't have to. What what do I mean? So what do we do? Yeah. Other comments. I would not use Talk. I use Talk. All right, Dan, what do you want to say? I was just going to say That's why you should never use Talk in a case like that. You say that every time Steve and I'm going to fight you for 11 more years. You've you I have recordings of you telling me that, but if you want it to stick. But there are other ways to treat it and the consequence of Talk are are so bad, should they ever need a chest operation on that side that there's no justification for it. So you do a half. All you need to do is have to go back into one chest that's been talked and it's uh it's it's it's it's an awful experience. And So what are you going to do if your recurrent recurrent recurrent pneumos? So well, you shouldn't if you treat it appropriately, you don't get that. You know what? I don't need to ask you anymore because I know what your answer is going to be. so. Well, you you know, you asked. Any other comments? Can I just have one other comment? of the matter that Talk is is is potentially potentially dangerous. I used to use it when I was uh a young attending because that was the the practice pattern in that time and then there was a paper. I I need to look it up that actually dissuaded me from using it uh as well. All right, Dan. just for malignant fusions. And recurrent recurrent recurrent Dan. I I was just going to make the comment about the, you know, what is sometimes a very frustrating process is a persistent air leak post surgery and uh we've had more experience lately with these endobronchial valves which work really, really well. So, that was just my comment. All right. This is a good discussion. I have a lot more maybe I'll change eventually. I'm a slow learner. All right. Ronnie, this was awesome. Uh clearly a lot of discussion.