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Manual Aspiration

The Preferred Method for Managing Primary Spontaneous Pneumothorax?

Pulmonary Disease Program Saint Thomas Hospital and Vanderbilt University Nashville, Tennessee

Several treatment options are available for the treatment of primary spontaneous pneumothorax. These include observation, supplemental oxygen, simple aspiration, tube thoracostomy with or without the instillation of a sclerosing agent, thoracoscopy, and open thoracotomy. In general, if the patient is asymptomatic and the pneumothorax occupies less than 20% of the hemithorax, no treatment is recommended.

If the pneumothorax is larger than 20% or if the patient is symptomatic, efforts to remove the air are indicated. Previously, there have been only a limited number of randomized controlled studies that addressed this topic (1), and no consensus exists concerning the treatment of these patients. A consensus statement from the American College of Chest Physicians recommended that the pleural air be removed via placement of a small-bore catheter ( 14F), or a 16F to 22F chest tube that may be attached to a Heimlich valve or to a water seal device (1). In contrast, the British Thoracic Society guidelines for the management of spontaneous pneumothorax recommend that the pleural air be removed by aspiration, and if the postaspiration chest radiograph reveals that the pneumothorax is small or resolved, that the chest tube be removed and the patient not be hospitalized (2). Schramel and colleagues have recommended that all symptomatic patients with primary spontaneous pneumothorax be subjected to thoracoscopy (3). This recommendation appears overly aggressive to me because approximately 50% of patients who have an initial primary spontaneous pneumothorax will never have another (4).

The study by Noppen and coworkers (pp. 1240–1244) in this issue of the American Journal of Respiratory and Critical Care Medicine (5) provides firm evidence that manual aspiration without hospitalization is an attractive alternative in the management of primary spontaneous pneumothorax. In their series of 27 patients treated with manual aspiration, the initial aspiration was successful in 16 patients (59%), and 13 of these 16 were not hospitalized (the remaining three were hospitalized because they requested it). Importantly, none of the patients who were initially successfully treated with manual aspiration had to be readmitted because of early recurrence of symptoms or the pneumothorax. Equally importantly, the rate of recurrence during the subsequent 12 months was basically identical in the patients treated with aspiration and in those treated with a chest tube.

One might be concerned that most of the recurrences would occur in those patients who are initially successfully treated with manual aspiration. I requested that the researchers provide data on this matter and, to my surprise, the recurrences were actually less common in the patients in whom the aspiration was initially successful. The rate of recurrence in the patients successfully treated with aspiration was 3 of 16 (19%), whereas it was 4 of 11 (36%) in patients in whom the aspiration was unsuccessful. If the 9 patients who were eventually treated with chest tubes in the aspiration group are combined with the 28 patients in the chest tube group who did not receive thoracoscopy, the rate of recurrence in the patients who received chest tubes was 13 of 37 (35%). Although this difference is not significant (p = 0.33, Fisher exact test), the results certainly suggest that the rate of recurrence with manual aspiration is not greater than the rate of recurrence with tube thoracostomy. One could hypothesize that the patients in whom aspiration is successful have smaller blebs than those in whom it fails.

The study by Noppen and coworkers (5) also demonstrates that if the initial manual aspiration is unsuccessful, a second aspiration is not likely to be successful because in their series a second aspiration failed in six of six patients. I agree with their explanation for this observation, which is that the initial aspiration failed because there was a persistent air leak, and therefore, a second aspiration was unlikely to be successful.

If manual aspiration fails, what should be the next step? It would seem reasonable that the patient should be hospitalized and a means provided for the continued removal of air. The easiest way to do this would be to secure the initial catheter with which the air was initially aspirated and then hook this catheter to a Heimlich valve or a water seal drainage system. If the air leak persists for more than 24 hours, I then recommend thoracoscopy with the stapling of blebs and pleural abrasion (4).

It should be noted that the study by Noppen and coworkers is not the first controlled study comparing manual aspiration with tube thoracostomy as the initial management in patients with spontaneous pneumothorax. Harvey and Prescott (6) randomized 73 patients with spontaneous pneumothorax and reported that the initial aspiration was successful in 23 of 35 patients (66%). Andrivet and associates (7) randomized 61 patients and reported that the initial aspiration was successful in 22 of 33 patients (67%). Interestingly, in both these studies, the rate of recurrence was lower in the patients treated successfully with manual aspiration than it was in the group treated with chest tubes (6, 7), as it was in the study by Noppen and coworkers (5). The primary difference between the study reported in this issue of the Journal (5) and the previous studies (6, 7) is that the present study was multicenter and had a longer follow-up than one of the previous studies (7).

Is there a place for manual aspiration in the treatment of other types of pneumothorax? I believe that most symptomatic iatrogenic pneumothoraces are best initially managed with manual aspiration (4). If the aspiration fails, then tube thoracostomy can be performed. I believe that most patients with secondary spontaneous pneumothoraces should not be managed with manual aspiration. Aspiration is less likely to be successful in these patients (8, 9), and the pneumothorax is more dangerous because of their limited lung reserve.

In conclusion, the study by Noppen and coworkers in this issue of the Journal (5), combined with the other reports in the literature, document that manual aspiration of the first occurrence of a primary spontaneous pneumothorax is an attractive treatment option. The advantage of this option is that more than 50% of the patients do not require hospitalization. If the aspiration is not successful, then a small-bore catheter or a chest tube is inserted and the patient is hospitalized. However, if the patient is unstable or has a tension pneumothorax, then a chest tube should be inserted and the patient should be hospitalized.

REFERENCES

1. Baumann MH, Strange C, Heffner JE, Light RW, Kirby TJ, Klein J, Luketich JD, Panacek EA, Sahn SA. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi Consensus Statement. Chest 2001;119:590–602.[Abstract/Free Full Text]
2. Miller AC, Harvey JE. Guidelines for the management of spontaneous pneumothorax. BMJ 1993;307:114–116.
3. Schramel FM, Sutedja TG, Braber JC, van Mourik JC, Postmus PE. Cost-effectiveness of video-assisted thoracoscopic surgery versus conservative treatment for first time or recurrent spontaneous pneumothorax. Eur Respir J 1996;9:1821–1825.[Abstract]
4. Light RW. Pleural diseases, 4th ed. Baltimore, MD: Lippincott, Williams & Wilkins; 2001.
5. Noppen M, Alexander P, Driesen P, Slabbynck H, Verstraeten A. Manual aspiration versus chest tube drainage in first episodes of primary spontaneous pneumothorax: a multicenter, prospective, randomized pilot study. Am J Respir Crit Care Med 2002;165:1240–1244.[Abstract/Free Full Text]
6. Harvey J, Prescott RJ. Simple aspiration versus intercostal tube drainage for spontaneous pneumothorax in patients with normal lungs. British Thoracic Society Research Committee. BMJ 1994;309:1338–1339.
7. Andrivet P, Djedaini K, Teboul J-L, Brochard L, Dreyfuss D. Spontaneous pneumothorax: comparison of thoracic drainage vs immediate or delayed needle aspiration. Chest 1995;108:335–340.[Abstract/Free Full Text]
8. Ng AW, Chan KW, Lee SK. Simple aspiration of pneumothorax. Singapore Med J 1994;35:50–52.[Medline]
9. Seaton D, Yoganathan K, Coady T, Barker R. Spontaneous pneumothorax: marker gas technique for predicting outcome of manual aspiration. BMJ 1991;302:262–265.

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