Advances in the Management of

Pneumothorax

RCP Update, 28th January 2019

Najib M Rahman
Professor of Respiratory Medicine
Oxford Pleural Unit
University of Oxford

Najib.rahman@ndm.ox.ac.uk
 Financial disclosures
• Drugs / placebos for clinical trials:
• Roche / Genentech / Boehringer / Lunamed / Syner-Med
• Technical equipment for trials:
• Rocket Medical UK / GE Medical / Esaote Medical /
• Trials unit funding:
• Roche / Syner-Med / GSK / Rocket Medical
• Clinical advice consultancy:
• Rocket Medical
• Trials consultancy:
• Lung Txics
• IP:
• Lipoteichoic acid for pleurodesis
• Research funding:
• NIHR / HTA trials / MRC / UKCRN / CRUK / BLF / UKNRCI
 Overview
• Initial management
• When to intervene
• How to intervene

• Ambulatory management

• Ongoing air leak

• Risk stratification

• Ideal patient pathway

 Not Covering

• Surgical techniques in recurrence prevention

• Iatrogenic / Traumatic pneumothorax
 Not Covering
• One Direction-Induced pneumothorax
 Not Covering
One Direction-Induced pneumothorax
 Case

26 year old man:

• 1 day history of chest pain
• Acute onset
• Cannabis smoker
 What is optimal first
Mx in this patient?
1. Observation
2. Pleural Aspiration
3. 12F intercostal drain
and admission
4. 12F intercostal drain
and Heimlich valve
5. 24F drain
6. Thoracic surgery
 Initial Management

Conservative vs Active Trials:

Study 1
“Justified general
• 119 cases overpolicy of non-intervention and
10 years
outpatient
• Conservatively management”
managed
• PSP (83%) & SSP (55%)

Study 2
• 242the
“Outline case
cases for 10
over active surgical management”
years
• Surgically managed
• 194 patients chest drains, 49 had thoracotomy
 Initial Management

• “Do nothing”
• Conservative approach - RCT

Brown SGA, BMJ Open 2016;6:e011826

BTS Pleural Disease Guidelines, Thorax 2010; 65 Suppl 2:ii4-17.
BTS Pleural Disease Guidelines, Thorax 2010; 65 Suppl 2:ii4-17.
BTS Pleural Disease Guidelines, Thorax 2010; 65 Suppl 2:ii4-17.
BTS Pleural Disease Guidelines, Thorax 2010; 65 Suppl 2:ii4-17.
Needle aspiration (NA) vs. Chest drain
 NA vs Chest drain
Aspiration Chest drain
success rate initial rate
Author Year n % % p value Note
1st or 2nd
Harvey* 1994 73 80% 100% ND
episode
Late
Andrivet* 1995 61 67% 93% 0.01
aspiration

Noppen 2002 60 59% 64% 0.9 1st episode

Ayed† 2006 137 62% 68% 0.4 1st episode

HoΔ 2011 48 48%Δ 72%Δ ND 1st episode

Parlakδ 2012 56 68% 81% 0.3 1st episode

*Excluded from original (2007) Cochrane r/v (as included 2nd episode PTx)
† Both arms placed on suction initially
Δ % discharged home after initial Rx (chest drain with Heimlich valve)
δ Included traumatic (22/56). ND: not done
 NA vs Chest drain
Aspiration Chest drain
success rate initial rate
Author Year n % % p value Note
1st or 2nd
Harvey* 1994 73 80% 100% ND
episode
Late
Andrivet* 1995 61 67% 93% 0.01
aspiration

Noppen 2002 60 59% 64% 0.9 1st episode

Ayed† 2006 137 62% 68% 0.4 1st episode

HoΔ 2011 48 48%Δ 72%Δ ND 1st episode

Parlakδ 2012 56 68% 81% 0.3 1st episode

*Excluded from original (2007) Cochrane r/v (as included 2nd episode PTx)
† Both arms placed on suction initially
Δ % discharged home after initial Rx (chest drain with Heimlich valve)
δ Included traumatic (22/56). ND: not done
 NA vs Chest drain
Aspiration Chest drain
success rate initial rate
Author Year n % % p value Note
1st or 2nd
Harvey* 1994 73 80% 100% ND
episode
Late
Andrivet* 1995 61 67% 93% 0.01
aspiration

Noppen 2002 60 59% 64% 0.9 1st episode

Ayed† 2006 137 62% 68% 0.4 1st episode

HoΔ 2011 48 48%Δ 72%Δ ND 1st episode

Parlakδ 2012 56 68% 81% 0.3 1st episode

*Excluded from original (2007) Cochrane r/v (as included 2nd episode PTx)
† Both arms placed on suction initially
Δ % discharged home after initial Rx (chest drain with Heimlich valve)
δ Included traumatic (22/56). ND: not done
 NA for Secondary PTx
Thelle 2017:
• Pragmatic RCT – NA versus CTD
• 127 patients
• 48 (38%) SSP

• 64 NA vs 63 CTD

Thelle A, Eur Respir J. 2017 Apr 12;49(4)

Thelle et al 2017
 Thelle et al 2017

Primary Secondary
 Current View of the data

Initial Management
• Needle aspiration (NA)
• Should this now include SSP?
• Should this include repeated attempts?

• If that fails
• Insert chest drain
• Small (≤14F) or Large bore drain?
 Size of chest tube
Size of initial tube:
• Small bore tube reasonable in initial treatment

(No direct RCT of tube size in PSP Rx)

Ambulatory Management
 What is the purpose of
Rx?
Purpose:
• Aspiration / Drain insertion does NOT repair air leak

• Intervention aimed at:

• Reducing symptoms
• Preventing tension

• What is the natural history of Ptx?

Waiting around in hospital is the problem
 Ambulatory Management

Theory:
• Increase mobility (reduce DVT/infection)
• Earlier discharge with device in situ
• Make the waiting more tolerable

Heimlich Valve
Pneumostat (Atrium)
Pleural Vent (Rocket)
 Ambulatory Management?

Current BTS Guidance

• Only in SSP unfit for surgery:

“Can be considered for ambulatory management

with a Heimlich valve”

What is required:
• Evidence of safety (especially home treatment)
• Evidence of efficacy
 Ambulatory Management?

• 18 studies
• Total >1200 patients using Heimlich valve
• OP management 77.9% successful

Data: “Poor quality with a high risk of bias”

 Recent Evidence

Studies since SR:

• Voisin (2014)
• n=132 (110 PSP)
• 78% success rate of pigtail catheter and valve

• Tsuchiya (2015)
• n=65 non-randomised comparison
• 36 (vent) vs 29 (chest drain)
• Shorter stay (5 vs 10 days) and less cost
 RAMPP
The Randomised Ambulatory Management of
Primary Pneumothorax Study

A randomised controlled trial to assess the effect of

ambulatory chest catheter drainage devices (Pneumovent)
in the treatment of primary pneumothorax to assess early
discharge and outpatient management
 RAMPP
Primary Spontaneous Pneumothorax

Requires Intervention

Yes - randomise

Pleural Standard Care

Vent Aspirate +/- Drain

23 UK recruiting sites
Randomised 230 / 240

12 month follow-up
1⁰ Outcome - Hospital Stay
(first 30 days)
Post initial management
 Ongoing Air Leak

24 hours of Rx

Drain in situ

Bubbling

Ptx size and pt stable

 What treatment is rational?

1. Second small drain

2. Larger bore drain
3. Suction
4. Observe
5. Thoracic surgery
 Post initial Mx
What does a chest tube achieve?
• Control of air leak
• Reduces symptoms
• Does not repair the visceral leak
 Physiology
Determinants of flow through a chest tube:

V = p2r5P / f x l

V=flow, r=radius, l=length, P=pressure, f=friction

Baumann et al, Chest 123:6, June 2003

Ongoing PTx

Observation
 Ongoing PTx
Data suggests*:
• Prolonged drainage (>7 days) will result in spontaneous
resolution of pneumothorax:

PSP
• 75% at 7 days
• 100% at 14 days

SSP
• 61% at 7 days
• 79% at 14 days
*Respir Med 1998;92:757-61.
 What treatment is rational?

1. Second small drain

2. Larger bore drain
3. Suction
4. Observe
5. Thoracic surgery
 What treatment is rational?

1. Second small drain

2. Larger bore drain
3. Suction
4. Observe
5. Thoracic surgery
 Worsening Clinical Status

With a bubbling drain

• Increasing PTx size

Suction
• SC emphysema Further drain
Larger drain
• Worsening clinical state
Endobronchial valves
Surgery
Risk Stratification
 What is the best predictor of
response to drainage?

1. Size of pneumothorax

2. Smoking history

3. Amount of bubbling

4. CT appearances
 Risk Prediction

Purpose:
• Predict which patients will respond to NA
• Predict early failure – who will have prolonged
air leak (PAL)

Enable triage of patients to direct strategy

 Predicting early failure

Can we better predict success with NA?

• Seaton (1991)

Seaton D, BMJ. 1991;302(6771):262-5

Kiely DG, Thorax. 2001 Aug;56(8):617-21.
 Predicting early failure

Assessment after aspiration and CXR improvement:

• Tracer gas –ve 96% no further Rx
• Tracer gas +ve 51% no further Rx
 Predicting early failure
Digital air leak measurement
(rather than flammable gas)

Air leak measurement with Thopaz in RAMPP

Predicting early failure

Hallifax et al, ATS 2018

Ideal patient pathway
 Ideal care pathway
PSP

Drainage

Prediction Model

Early resolver Moderate and safe Prolonged leak

Ambulatory Direct thoracic

Treatment surgery

?Total outpatient management of PTX?

 Summary

• Conservative treatment – await RCT data

• Needle Aspiration should be first line Rx

• Ambulatory Mx – possibly the way forward

• Early risk stratification – using air leak

• Triage patients using personalised model?

 Acknowledgments
INVESTIGATORS ORTU TSC / DMC MRC CTU
J. Pepperell A. Chauhan E. Mishra J. Pepperell B. Kahan
T. Saba A. Leonard J. Wrightson N.A. Maskell D. Bratton
A. Tang S. Fowler E. Hedley Y.C.G. Lee A. Bara
N. Ali A. Ionescu N. Crosthwaite A. West A. Nunn
A. West J. Kastelik B. McFadyen A.J. Nunn
M. Laskawiec-Szkonte S. Rehal
G. Hettiarachchi H. Davies S. Rehal
R. Shaw G. Wills
D. Mukerjeey A. Stanton E.Hedley
J. Samuel C. Davies M. Dobson R. Shaw
A. Bentley A. Guhan M. Chapman D. Seaton
L. Dowson J. Grayez J. Quaddy R.F. Miller
J. Miles R. Harrison J. Corcoran
F. Ryan A. Prasad R. Hallifax
K. Yoneda A. Clive H. Davies
M. Al-Aloul A. Hart-Thomas RJO Davies Funding
I. Psallidas MRC UK
M. Evison R. Harrison
RJO. Davies NIHR BRC
A. Guhan M. Callister CLRN
R. Sathyamurthy N. Maskell NCRI
BLF
Synermed UK
Rocket Medical UK