Tag Archives: procedures

Acute Med, All Updates, ICU, Resus, Ultrasound

Posterior pericardiocentesis

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Dr Emanuele Catena and colleagues report a case of an adult male who presented 7 days post cardiac surgery with simultaneous pleural and pericardial effucions causing dyspnoea, tachycardia and hypotension.

Old skool pericardiocentesis

His pericardial effusion was posterior which usually requires surgical drainage, but the adjacent left pleural effusion was associated with pulmonary atelectasis and displacement of the lung, allowing them to insert a needle using sonographic guidance first into the pleural space then the pericardial space.
They inserted through the fourth intercostal space 4 cm medially to the left posterior axillary line (with the patient positioned in the semireclining position). They used agitated saline bubbles to confirm first the pleural then the pericardial location of the needle tip. A 30-cm-long catheter was introduced into the posterior pericardium using the Seldinger technique, and serous-haemorrhagic fluid was drained. The catheter was then retracted allowing drainage of the pleural effusion.
The procedure resulted in haemodynamic and respiratory improvement.
The authors summarise:


This case reports the technique of a “back pericardiocentesis” performed under echographic guidance as a valid alternative to surgery in the peculiar situation characterized by the simultaneous presence of a large left pleural effusion. In the presence of a large left pleural effusion, pulmonary atelectasis and displacement of air-filled pulmonary tissue allows ultrasound transmission from a patient’s back to the heart through a liquid interface and needle insertion “from back” to reach the pericardial space.

 
Pericardiocentesis From Back Under Echographic Guidance An Approach for Posterior Pericardial Effusions
Circulation. 2011 Dec 13;124(24):e835-6

All Updates, PHARM, Resus, Trauma

Prehospital thoracostomy tube misplacement

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An interesting study from Germany examined prehospital thoracostomy tube (TT) placement by physicians working in the field. Of 69 patients who received them, 67 underwent prehospital intubation. 88 TT were placed in the 69 patients.
There were 19/88 (22%) radiologic chest tube misplacements (defined as too far in the chest, twisted, or bent). The position of 10/88 (11%) chest tubes had to be corrected. None of the patients with a TT had a “not-decompressed” pneumothorax or a chest tube placed below the diaphragm or into a solid organ.
Roughly half were placed in the ‘Monaldi’ position (the second or third intercostal space in the midclavicular line)…..

Monaldi position

 
 
 
 
 
 
 
 
 
…..and half in the Bülau position (fourth or fifth intercostal space in the midaxillary line).
Bülau position

 
 
 
 
 
 
 
 
 
There was no difference in the misplacement rates between the two positions although interestingly helicopter doctors (as opposed to ground response) more often opted for the Monaldi position.
It is not possible to tell from the results whether the TT insertion was indicated in all cases. Also, it would be interesting to know whether TT insertion preceded or followed tracheal intubation. While it is heartening that these physicians do not routinely rely on needle decompression, I cannot fathom while simple open thoracostomy was not used, avoiding the risk of tube misplacement and saving time.
See this post for a more thorough review of open thoracostomy and the limitations of needle decompression.


Objectives. To evaluate the frequency of use, placement site, success and misplacement rates, and need for intervention for tube thoracostomies (TTs), and the complications with endotracheal intubation associated with TT in the prehospital setting.

Methods. We performed a five-year, retrospective study using the records of 1,065 patients who were admitted to the trauma emergency room at a university hospital and who had received chest radiographs or computed tomography (CT) scans within 30 minutes after admission.

Results. Seven percent of all patients received a TT (5% unilateral, 2% bilateral). Ninety-seven percent of all patients with a TT were endotracheally intubated. The success rate for correctly placed chest tubes was 78%. Twenty-two percent of the chest tubes were misplaced (i.e., too far in the chest, twisted, or bent); half of those had to be corrected, with one needing to be replaced. There were no statistical differences in the frequency of Monaldi or Bülau positions, or the frequency of left or right chest TT. In addition, the two positions did not differ in misplacement rates or the need for intervention. Helicopter emergency medical services physicians used the Monaldi position significantly more frequently than the Bülau position. In-hospital physicians performing interhospital transfer used the Bülau position significantly more frequently, whereas ground emergency medical physicians had a more balanced relationship between the two positions. Tube thoracostomy had no influence on endotracheal tube misplacement rates, and vice versa.

Conclusion. Tube thoracostomy positioning mostly depends on the discretion of the physician on scene. The Monaldi and Bülau positions do not differ in misplacement or complication rates.

Incidence And Outcome Of Tube Thoracostomy Positioning In Trauma Patients
Prehosp Emerg Care. 2011 Oct 3. [Epub ahead of print]

All Updates, ICU, Kids, PHARM, Resus

A big brain saves a little one

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Something I’ve been teaching for years – but never actually done – has been described in a case report from Oman.
A 2 year old child suffered a respiratory arrest due to an inhaled foreign body, which led to a bradyasystolic cardiac arrest. She was intubated by the resuscitation team who could not achieve any ventilation through the tube. The tube was removed and reinserted by an ‘expert’ (there is no mention of capnometry, for what it’s worth) and the same problem persisted.
The life-saving manouevre was to insert the tracheal tube further down into the right main bronchus and then withdraw to the trachea. This forced the obstructing object distally so that one-lung ventilation was then possible, resulting in return of spontaneous circulation and oxygen saturations in the mid-80’s. The object – a broken piece of plastic – was removed bronchoscopically and happily the child made an uneventful recovery.
Is this technique in your list of life-saving tricks? Hopefully, it is now.
A child is alive because a doctor was able to ‘think outside the guidelines’ in an incredibly high pressure situation. Rigid adherence to ACLS procedures here would have been futile. The guidelines save lives, but a few more can be saved when care can be individualised to the clinical situation by a thinking clinician.
Well done Dr Mishra and colleagues.

Sudden near-fatal tracheal aspiration of an undiagnosed nasal foreign body in a small child
Emerg Med Australas. 2011 Dec;23(6):776-8
[And here’s something else to consider if you have no airway equipment with you and your basic choking algorithm isn’t working]

All Updates, ICU, PHARM, Resus

Emergency percutaneous airway

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An excellent thorough review of emergency needle and surgical cricothyroidotomy – collectively described as ’emergency percutaneous airway’ – reveals a number of pearls.
Regarding anatomy:

  • The cricothyroid menbrane has an average height of 10 mm and a width of 11 mm
  • Transverse incision in the lower half of the cricothyroid membrane is recommended to avoid the cricothyroid arteries and the vocal cords

Regarding oxygenation / ventilation via a cricothyroid needle:

  • High pressure source ventilation via a needle (eg. by Sanders injector or Manujet) may cause laryngospasm, so a neuromuscular blocking agent should be considered
  • Barotrauma may result from an obstructed upper airway, so efforts should be made to maintain upper airway patency where possible (eg. with a supraglottic airway)
  • A device has been manufactured that provides suction-generated expiratory ventilation assistance (using oxygen flow and the Bernoulli principle) – the Ventrain
  • The Fourth National Audit Project reported a much lower success rate and described several complications of attempted re-oxygenation via a narrow-bore cricothyroidotomy
  • Where there is no kink-resistant cannula or suitable high-pressure source ventilation device readily available, it is probably safer to perform a wide-bore cannula puncture or surgical cricothyroidotomy.

Wide-bore cannula-over trocar devices:

  • Include the Quicktrach II and Portex cricothyroidotomy kit
  • Sometimes require considerable force to push the device through the cricothyroid membrane, risking compression of the airway and damage or perforation of the posterior tracheal wall.

Seldinger cricothyroidotomy kits:

  • Separate the puncture and dilatation steps, minimising the risk of trauma
  • Include the Melker emergency cricothyroidotomy set, available in sizes 3.0–6.0 mm ID
  • Tend to be preferred by anaesthetists over the surgical and wide-bore cannula-over-trocar techniques
  • Seldinger technique in human cadavers and manikin studies by those well trained, inexperienced operators have low success rates and a long performance time

What about after?

  • High-pressure source ventilation may aid subsequent intubation by direct laryngoscopy as bubbles may be seen emerging from the glottis.
  • The Seldinger technique has been recommended to convert a narrow-bore cannula into a cuffed wide-bore cricothyroidotomy
  • While conversion of cricothyroidotomy to tracheostomy within 72 h has been advocated because of the increased risk of developing subglottic stenosis with prolonged intubation through the cricothyroid membrane, this risk may be much lower than previously believed
  • The risk of conversion, although less well examined, may also be appreciable

Which technique is best?

  • The recent NAP4 audit reported a success rate of only 37% for narrow-bore cannula-over-needle cricothyroidotomy, 57% for wide-bore cannula techniques and 100% for surgical cricothyroidotomy
  • Simulation studies show conflicting results about whether seldinger or surgical technique is faster.
  • Reported success rates of the different techniques (in simulations) also vary widely and range for surgical cricothyroidotomy from 55% to 100%, for wide-bore cannula-over-trocar from 30% to 100%, and for Seldinger technique from 60% to 100%.

The one area of some consensus is that conventional (low-pressure source) ventilation should not be used with a narrow-bore cannula; a high-pressure oxygen source and a secure pathway for the egress of gas are both mandatory to achieve adequate ventilation.
Complications may be related to technique:

  • Complications of narrow-bore cannula techniques are ventilation-related and include barotrauma, subcutaneous emphysema, pneumothorax, pneumomediastinum and circulatory arrest due to impaired venous return; Cannula obstruction due to kinking also occurs.
  • Seldinger technique may be complicated by kinking of the guidewire, which increases the risk of tube misplacement
  • Bleeding and laryngeal fracture may complicate the surgical method, and long-term complications include subglottic stenosis, scarring and voice changes.

Equipment and strategies for emergency tracheal access in the adult patient
Anaesthesia. 2011 Dec;66 Suppl 2:65-80

All Updates, ICU, PHARM, Resus

Listen over the neck when inflating ETT cuff

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This interesting study introduces a novel technique for guiding the inflation of tracheal tube cuffs to avoid excessive cuff pressures: listening with a stethoscope over the thyroid cartilage and inflating the cuff until breath sounds change from harsh to soft.


Tracheal tube cuffs are commonly inflated to pressures exceeding the recommended upper limit of 30 cmH2O. We evaluated whether a stethoscope-guided method of cuff inflation results in pressures within the recommended range. Patients were randomly assigned to receive one of two methods of cuff inflation. In the standard ‘just seal’ group, air was introduced into the tracheal cuff until the audible leak at the mouth disappeared. In the stethoscope-guided group, air was introduced into the cuff until a change from harsh to soft breath sounds occurred, whilst listening with a stethoscope bell placed over the thyroid cartilage. Twenty-five patients were recruited
to each group. The median (IQR [range]) cuff pressure in the ‘just seal’ group was 34 (28–40 [18–49]) cmH2O, and in the stethoscope-guided group was 20 (20–26 [16–28]) cmH2O,
p < 0.0001. The stethoscope-guided method of tracheal tube cuff inflation is a novel, simple technique that reliably results in acceptable tracheal cuff pressures.

Clinical evaluation of stethoscope-guided inflation of tracheal tube cuffs
Anaesthesia. 2011 Nov;66(11):1012-6

Acute Med, All Updates, Resus, Trauma

Modified ED thoracotomy to avoid exsanguination

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Emergency physicians from Minnesota (and graduates of the amazing Hennepin Emergency Medicine Residency) describe a patient who developed cardiac tamponade after an ablation procedure for dysrhythmia. Attempts at pericardiocentesis by both emergency and cardiology staff were hindered by clotted blood, and so a left lateral thoracotomy was performed in the ED due to loss of pulse and lack of immediate availability of an operating room. A limited pericardial incision was made to allow drainage of sufficient blood to relieve tamponade while avoiding catastrophic blood loss from the underlying lesion, which turned out to be a 1.5-cm hole in the right ventricular outflow tract. The patient made a full recovery.

Cardiac dysrhythmias are a common problem in the United States. Radiofrequency ablation is being used more frequently as a treatment for these diagnoses. Although rare, serious complications such as cardiac tamponade have been reported as a result of ablation procedures. Traditionally, emergency department (ED) thoracotomy has been reserved for cases of traumatic arrest only. We report a case of a successful modified ED thoracotomy in a patient with postablation cardiac tamponade and subsequent obstructive shock who failed intravenous fluid resuscitation, pressor administration, and multiple attempts at pericardiocentesis. In this case, a modified approach was used to incise the pericardium. Although this was associated with large blood loss, we believed that using the traditional method of completely removing the pericardium would have resulted in uncontrolled hemorrhage. Instead, our method led to successful resuscitation of the patient until definitive care was available. A smaller pericardial incision than is traditionally used during ED thoracotomy deserves further consideration and research to determine whether and when it may be most useful as a temporizing treatment of cardiac tamponade when other methods have failed.

Modified Emergency Department Thoracotomy for Postablation Cardiac Tamponade
Annals of Emergency Medicine In Press – Full Text Available here from Annals site at time of blogging

All Updates, PHARM, Resus, Trauma

More on needle thoracostomy for tension pneumothorax

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Thanks to Dr. Matthew Oliver for highlighting these articles to me.
The standard teaching of placing a handy iv catheter in the 2nd intercostal space, midclavicular line for tension pneumothorax has been challenged by previous studies suggesting about a third of adults have a chest wall that is too thick for a standard 4.5 to 5 cm needle.
Some have therefore suggested that a lateral approach may be more appropriate.
Three studies this month provide more, although not entirely consistent, information.
An ultrasound study differed from previous CT studies by suggesting that most patients will have chest wall thickness (CWT) less than 4.5 cm, and found that the CW was thicker in the lateral area (4th intercostal space, midaxillary line)1.
In a cadaveric model, needle thoracostomy was successfully placed (confirmed by thoracotomy) in all attempts at the fifth intercostal space at the midaxillary line but in only just over half of insertions at the traditional second intercostal position2.
In a further study of trauma CT scans, measured CWT suggests that the lateral approach is less likely to be successful than the anterior approach, and the anterior approach may fail in many patients as well3.

The take home message for us must therefore remain that needle thoracostomy for tension pneumothorax might not be successful with a standard iv catheter, regardless of which approach is used. If tension pneumothorax is a possibility in the deteriorating patient and needle decompression has been unsuccessful, an alternative means of decompression (or ruling out pneumothorax) must be employed.

1. Ultrasound determination of chest wall thickness: implications for needle thoracostomy
Am J Emerg Med. 2011 Nov;29(9):1173-7
[EXPAND Abstract]


Objective: Computed tomography measurements of chest wall thickness (CWT) suggest that standard- length angiocatheters (4.5 cm) may fail to decompress tension pneumothoraces. We used an alternative modality, ultrasound, to measure CWT. We correlated CWT with body mass index (BMI) and used national data to estimate the percentage of patients with CWT greater than 4.5 cm.

Methods: This was an observational, cross-sectional study of a convenience sample. We recorded standing height, weight, and sex. We measured CWT with ultrasound at the second intercostal space, midclavicular line and at the fourth intercostal space, midaxillary line on supine subjects. We correlated BMI (weight [in kilograms]/height2 [in square meters]) with CWT using linear regression. 95% Confidence intervals (CIs) assessed statistical significance. National Health and Nutrition Examination Survey results for 2007-2008 were combined to estimate national BMI adult measurements.

Results: Of 51 subjects, 33 (65%) were male and 18 (35%) were female. Mean anterior CWT (male, 2.1 cm; CI, 1.9-2.3; female, 2.3 cm; CI, 1.7-2.7), lateral CWT (male, 2.4 cm; CI, 2.1-2.6; female, 2.5 cm; CI 2.0-2.9), and BMI (male, 27.7; CI, 26.1-29.3; female, 30.0; CI, 25.8-34.2) did not differ by sex. Lateral CWT was greater than anterior CWT (0.2 cm; CI, 0.1-0.4; P < .01). Only one subject with a BMI of 48.2 had a CWT that exceeded 4.5 cm. Using national BMI estimates, less than 1% of the US population would be expected to have CWT greater than 4.5 cm.
Conclusions: Ultrasound measurements suggest that most patients will have CWT less than 4.5 cm and that CWT may not be the source of the high failure rate of needle decompression in tension pneumothorax.

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2. Anterior versus lateral needle decompression of tension pneumothorax: comparison by computed tomography chest wall measurement.
Acad Emerg Med. 2011 Oct;18(10):1022-6
[EXPAND Abstract]


Objectives:  Recent research describes failed needle decompression in the anterior position. It has been hypothesized that a lateral approach may be more successful. The aim of this study was to identify the optimal site for needle decompression.

Methods:  A retrospective study was conducted of emergency department (ED) patients who underwent computed tomography (CT) of the chest as part of their evaluation for blunt trauma. A convenience sample of 159 patients was formed by reviewing consecutive scans of eligible patients. Six measurements from the skin surface to the pleural surface were made for each patient: anterior second intercostal space, lateral fourth intercostal space, and lateral fifth intercostal space on the left and right sides.

Results:  The distance from skin to pleura at the anterior second intercostal space averaged 46.3 mm on the right and 45.2 mm on the left. The distance at the midaxillary line in the fourth intercostal space was 63.7 mm on the right and 62.1 mm on the left. In the fifth intercostal space the distance was 53.8 mm on the right and 52.9 mm on the left. The distance of the anterior approach was statistically less when compared to both intercostal spaces (p <  0.01).
Conclusions:  With commonly available angiocatheters, the lateral approach is less likely to be successful than the anterior approach. The anterior approach may fail in many patients as well. Longer angiocatheters may increase the chances of decompression, but would also carry a higher risk of damage to surrounding vital structures.

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3. Optimal Positioning for Emergent Needle Thoracostomy: A Cadaver-Based Study
J Trauma. 2011 Nov;71(5):1099-1103/a>
[EXPAND Abstract]


Background:  Needle thoracostomy is an emergent procedure designed to relieve tension pneumothorax. High failure rates because of the needle not penetrating into the thoracic cavity have been reported. Advanced Trauma Life Support guidelines recommend placement in the second intercostal space, midclavicular line using a 5-cm needle. The purpose of this study was to evaluate placement in the fifth intercostal space, midaxillary line, where tube thoracostomy is routinely performed. We hypothesized that this would result in a higher successful placement rate.

Methods:  Twenty randomly selected unpreserved adult cadavers were evaluated. A standard 14-gauge 5-cm needle was placed in both the fifth intercostal space at the midaxillary line and the traditional second intercostal space at the midclavicular line in both the right and left chest walls. The needles were secured and thoracotomy was then performed to assess penetration into the pleural cavity. The right and left sides were analyzed separately acting as their own controls for a total of 80 needles inserted into 20 cadavers. The thickness of the chest wall at the site of penetration was then measured for each entry position.

Results:  A total of 14 male and 6 female cadavers were studied. Overall, 100% (40 of 40) of needles placed in the fifth intercostal space and 57.5% (23 of 40) of the needles placed in the second intercostal space entered the chest cavity (p < 0.001); right chest: 100% versus 60.0% (p = 0.003) and left chest: 100% versus 55.0% (p = 0.001). Overall, the thickness of the chest wall was 3.5 cm ± 0.9 cm at the fifth intercostal space and 4.5 cm ± 1.1 cm at the second intercostal space (p < 0.001). Both right and left chest wall thicknesses were similar (right, 3.6 cm ± 1.0 cm vs. 4.5 cm ± 1.1 cm, p = 0.007; left, 3.5 ± 0.9 cm vs. 4.4 cm ± 1.1 cm, p = 0.008).
Conclusions:In a cadaveric model, needle thoracostomy was successfully placed in 100% of attempts at the fifth intercostal space but in only 58% at the traditional second intercostal position. On average, the chest wall was 1 cm thinner at this position and may improve successful needle placement. Live patient validation of these results is warranted.

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Update October 2012: See this post about a further CT-scan based study favouring the 5th ICS compared with the 2nd

All Updates, PHARM, Resus, Trauma, Ultrasound

Tension pneumo treatment and chest wall thickness

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An interesting ultrasound-based study challenges the assertion that a significant proportion of adults have a chest wall that is too thick for a standard iv cannula to reach the pleural space when attempting to decompress a tension pneumothorax. Perhaps there are other factors that make this technique so frequently ineffective.
The authors postulate that ultrasound measurements of chest wall thickness might be less than those obtained by CT scan due to the downward pressure on the tissues caused when the ultrasound transducer is placed on the chest, something that may also occur when a cannula is being pushed in, but would not be maintained after insertion of a cannula, perhaps leading to subsequent misplacement as the tissues recoil.
My view is that needle decompression might buy you time as a holding measure, but the patient with a tension pneumothorax will need a thoracostomy sooner rather than later.


Objective: Computed tomography measurements of chest wall thickness (CWT) suggest that standard- length angiocatheters (4.5 cm) may fail to decompress tension pneumothoraces. We used an alternative modality, ultrasound, to measure CWT. We correlated CWT with body mass index (BMI) and used national data to estimate the percentage of patients with CWT greater than 4.5 cm.

Methods: This was an observational, cross-sectional study of a convenience sample. We recorded standing height, weight, and sex. We measured CWT with ultrasound at the second intercostal space, midclavicular line and at the fourth intercostal space, midaxillary line on supine subjects. We correlated BMI (weight [in kilograms]/height2 [in square meters]) with CWT using linear regression. 95% Confidence intervals (CIs) assessed statistical significance. National Health and Nutrition Examination Survey results for 2007-2008 were combined to estimate national BMI adult measurements.

Results: Of 51 subjects, 33 (65%) were male and 18 (35%) were female. Mean anterior CWT (male, 2.1 cm; CI, 1.9-2.3; female, 2.3 cm; CI, 1.7-2.7), lateral CWT (male, 2.4 cm; CI, 2.1-2.6; female, 2.5 cm; CI 2.0-2.9), and BMI (male, 27.7; CI, 26.1-29.3; female, 30.0; CI, 25.8-34.2) did not differ by sex. Lateral CWT was greater than anterior CWT (0.2 cm; CI, 0.1-0.4; P <.01). Only one subject with a BMI of 48.2 had a CWT that exceeded 4.5 cm. Using national BMI estimates, less than 1% of the US population would be expected to have CWT greater than 4.5 cm.
Conclusions: Ultrasound measurements suggest that most patients will have CWT less than 4.5 cm and that CWT may not be the source of the high failure rate of needle decompression in tension pneumothorax.

Ultrasound determination of chest wall thickness: implications for needle thoracostomy

Am J Emerg Med. 2011 Nov;29(9):1173-7

All Updates

Saving Lives Through Failure

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Think about what you would do if faced with the following situation:

You sedate and paralyse a patient with severe injuries in order to intubate them. You are unable to intubate due to a poor view and massive orofacial haemorrhage. An iGel provides temporary oxygenation while you prepare for a surgical airway.

Your first surgical airway attempt fails due to insertion of the bougie through a false (too superficial) passage. You spot your mistake and re-do the procedure successfully with a deeper incision. The patient’s airway is secure and there is good oxygenation and ventilation.

You discover that a colleague has videoed the procedure on his iPhone. However he only captured the first, unsuccessful attempt. The patient is not identifiable in the close up video. It’s late at night and only he and you know of the existence of the video. He asks you what you want him to do with it.



Do you…
(a) Ask your colleague to delete the video?
(b) Watch the video with him and look for learning points, and then delete it?
(c) Ask him for a copy of it and request that he doesn’t show it to anyone else?
(d) Other course of action
Consider your course of action given this situation, and then click below to reveal what my colleague did recently in exactly the same scenario…
[EXPAND What did he do?]
(d) He did something else entirely: he got a copy of the video, burned it onto a CD, and left it on his boss’s desk!

It takes a certain kind of practitioner to risk embarrassment and criticism in the pursuit of the greater educational good.

He had already ascertained what he would need to do differently next time, so had nothing personal to gain from his chosen action.

Instead, he believed that sharing the video would help prevent his colleagues from repeating the same mistake, and help his supervisors review their cricothyroidotomy training in order to better prepare their team for the procedure. Ultimately, this gesture was directed towards the good of our patients.

His actions may have saved more than one life that evening.

[/EXPAND]

Acute Med, All Updates, Resus

Needle versus mini-chest tube for pneumothorax

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A mini-chest tube with Heimlich valve was an alternative to needle aspiration in patients with spontaneous pneumothorax, with some apparently favourable outcomes in this small study. The authors do not specify what type of chest tube they used but report it was 12 Fr diameter. They highlight an interesting difference in guidelines for the treatment of spontaneous primary pneumothorax:
“Traditional preference has been for chest tube insertion and admission to the ward. British Thoracic Society recommends needle aspiration (NA) as the initial treatment of choice, but American College of Chest Physicians Consensus prefers insertion of small-bore catheters (≤14F) or chest tubes (16-22F).”


OBJECTIVES: The aim of this study was to compare outcomes and complications associated with needle aspiration (NA) and minichest tube (MCT) insertion with Heimlich valve attachment in the treatment of primary spontaneous pneumothorax at an emergency department (ED).

METHODS: Patients presenting with primary spontaneous pneumothorax were randomized to NA or MCT. They had repeat chest x-rays immediately after the procedure and 6 hours later. Patients who underwent NA were discharged if repeat x-rays showed less than 10% pneumothorax. Those who had MCT were discharged if repeat x-rays did not show worsening of pneumothorax. They were reviewed at the outpatient clinic within 3 days. The primary outcomes of interest were failure rate and admission rate. The secondary outcomes were complication rate, pain and satisfaction scores, length of hospital stay, and rate of full recovery during outpatient follow-up.

RESULTS: There were 48 patients whose mean age was 25 years. We found no difference in failure rate between the groups, except that there were more MCT (24%) than NA patients (4%) with complete expansion at first review (difference, -0.20; 95% confidence interval, -0.38 to -0.01). Thirty-five percent of NA group and 20% of MCT group needed another procedure at the ED. Fifty-two percent of NA patients and 28% of MCT patients were admitted from the ED to the inpatient ward. Nine percent and 12%, respectively, of patients who had NA and MCT were admitted from the review clinic. Both groups of patients had equivalent pain scores, satisfaction scores, and complication rates.

CONCLUSION: Both MCT and NA allowed safe management of primary spontaneous pneumothorax in the outpatient setting.

A randomized controlled trial comparing minichest tube and needle aspiration in outpatient management of primary spontaneous pneumothorax
Am J Emerg Med. 2011 Nov;29(9):1152-7