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Eur J Cardiothorac Surg 2007;31:491-495. doi:10.1016/j.ejcts.2006.12.011
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved

Can spontaneous pneumothorax patients be treated by ambulatory care management?

Sung Hyuk Choia,*, Sung Woo Leea,b, Yun Sik Honga,c, Su Jin Kima,b, Jun Dong Moona,d, Sung Woo Moona,c

a Department of Emergency Medicine, College of Medicine, Korea University, Seoul, South Korea
b Korea University Ansan Hospital, Ansan, Gyeonggi-Do, South Korea
c Korea University Anam Hospital, Seoul, South Korea
d Korea University Guro Hospital, Seoul, South Korea

Received 2 November 2006; received in revised form 7 December 2006; accepted 12 December 2006.

* Corresponding author. Address: Emergency Department, Korea University Guro Hospital, 80 Guro 2-Dong, Guro-Gu, Seoul 152-703, South Korea. Tel.: +822 818 6286; fax: +822 818 6284. (Email: kuedchoi{at}korea.ac.kr).


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 
Objective: In the Emergency Department, it would be worthwhile to treat pneumothorax patients on an outpatient basis by utilizing a small-calibre catheter and Heimlich valve insertion. We evaluated this treatment and compared it with the closed thoracostomy. Methods: In this comparative study, the success rate, complications and recurrence rate of treating spontaneous pneumothorax patients by using a small-calibre catheter and Heimlch valve were compared with those of a similar-sized group treated by closed thoracostomy. Results: Pneumothorax was successfully treated on an ambulatory basis by using the small-calibre catheter and Heimlch valve in 20 patients (47%); this was less than the 42 patients (89%) who were successfully treated by closed thoracostomy. While no complications were encountered in the group treated using the small-calibre catheter and Heimlich valve, 11 patients in the group treated by closed thoracostomy developed complications. The medical expenses for the treatment involving the small-calibre catheter and Heimlich valve were less than those for closed thoracostomy. Conclusion: Prior to the treatment, the patients should be fully informed of the success rate of this treatment and the possibility of requiring closed thoracostomy in the event of treatment failure.

Key Words: Pneumothorax • Thoracostomy • Emergencies • Outpatients • Crowding


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 References
 
In hospital emergency departments, closed thoracostomy and hospitalization are commonly recommended for cases of pneumothorax, most of which are of spontaneous aetiology. However, this has given rise to issues such as overcrowding in emergency departments, patient discomfort and high medical expenses. Treatment guidelines for the management of pneumothorax patients include monitoring of the clinical course, use of a small-calibre catheter and closed thoracostomy performed based on the severity and magnitude of their symptoms [1]. However, at emergency centres in Korea, small-calibre catheters are rarely employed for the outpatient treatment of pneumothorax; furthermore, their use is associated with dissatisfaction in patients if failure of this treatment necessitates hospitalization for closed thoracostomy as secondary treatment.

Therefore, this study aimed to determine the success rate of outpatient treatment with small-calibre catheters and factors resulting in failure as well as to compare the success rate of this outpatient treatment with that of closed thoracostomy.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 References
 
We studied 50 pneumothorax patients who were treated with an 8 F small-calibre catheter and Heimlich valve between January 2005 and June 2006 in our emergency department. We excluded two patients who were lost to follow-up and one patient with iatrogenic pneumothorax. Finally, the baseline data of 47 patients, including factors such as age, sex, onset time, major symptoms, size of pneumothorax, success rate, complications, recurrence rate and length of treatment, were analyzed and compared with that of a similar-sized group treated by closed thoracostomy. We also examined the factors affecting the success of treatment. Only patients with spontaneous pneumothorax were included; those with trauma or pneumothorax accompanied by pleural effusion, empyema or haemothorax and haemodynamically unstable patients were excluded.

All procedures were performed by an emergency physician. In the experimental group, catheter insertion was performed using a needle inserted into the fifth intercostal space in the anterior axillary line or the second intercostal space in the midclavicular line. Then, a Heimlich valve (Pneumothorax Set, Arrow International, Pennsylvania, USA) was connected to the catheter. A chest X-ray was performed 3–4 h later. Patients with less than 10% residual pneumothorax on chest X-ray were allowed to undergo ambulatory treatment. In patients with persistent pneumothorax, however, aspiration was attempted by connecting the Heimlich valve to a water-seal system overnight. On day 2, the patients again underwent chest X-ray. Ambulatory treatment was allowed in these patients if no residual pneumothorax was observed on chest X-ray and at follow-up assessment on days 4 and 6. Patients in whom pneumothorax was identified on chest X-ray underwent closed thoracostomy and were hospitalized. In the control group, the chest radiographic findings of 47 patients were evaluated on days 2, 4 and 6 (Fig. 1 ); they underwent closed thoracostomy and were hospitalized.


Figure 1
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  		Fig. 1. Flow diagram comparing the outcome of treatment with an 8 F small-calibre catheter plus Heimlich valve and that by closed thoracostomy.

 
In the experimental group, the successful treatment was defined as catheter removal after complete pulmonary expansion and in the absence of air leakage. In the control group, it was defined as the presence of complete pulmonary expansion; this is because the decision regarding undergoing additional video-assisted thoracoscopic surgery lay with the patients in this group. Based on the above conditions, treatment outcome, complications (pleural effusion, empyema, haemothorax or subcutaneous emphysema), recurrence rate (pneumothorax recurrence within 6 months) and medical expenses were assessed between the two groups. In the experimental group, the medical expenses were defined as the total cost borne by a patient until the end of treatment; in the control group, it was the amount spent by a patient from hospitalization to discharge, excluding the cost of operation. This study was approved by the Korea University Ethics Committee.

For statistical analysis, data were compared by Student's t-test and Chi-square test using SPSS ver. 11.5 (SPSS Inc., Chicago, IL, USA) for windows. Statistical significance was set at p < 0.05.


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 References
 
Our series included 39 males and 8 females. Among these, 13 patients were in their teens; 28, twenties; 3, thirties; 2, fifities and 1 patient, sixties. The chief complaints were dyspnoea or chest pain; the pneumothorax was of spontaneous aetiology and was the first attack. The iatrogenic pneumothorax in a patient was successfully treated using a small-calibre catheter and Heimlich valve. However, this patient was excluded from the analysis because the study included patients with only spontaneous pneumothorax. Tuberculosis was the underlying pulmonary disease in four patients. The pneumothorax varied in size and was estimated at 17% in 1 patient, 20–39% in 27, 40–59% in 12 and more than 60% in seven patients [2,3]. The catheter was inserted into the fifth intercostal space in the anterior axillary line in 30 patients and into the second intercostal space in the midclavicular line in 17 patients (Table 1 ).


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  		Table 1 Comparison of clinical characteristics between the two groups
 
In 13 patients, complete pulmonary expansion was not achieved after treatment with a small-calibre catheter and Heimlich valve or residual pneumothorax was observed on chest X-ray on day 2. These patients were hospitalized after they underwent closed thoracostomy using a 28 F catheter. The remaining 34 patients were permitted to undergo ambulatory treatment. On days 4 and 6, pneumothorax was identified in 14 patients despite the presence of the Heimlich valve. These patients underwent closed thoracostomy using a 28 F catheter and were hospitalized. In total, ambulatory treatment for pneumothorax was successful in 43% patients (20/47). Pulmonary expansion was absent on the next day in five patients who received treatment with the water-seal device.

In the control group, in which closed thoracostomy was performed, persistent pneumothorax was observed in five patients, and the remaining 42 patients showed pulmonary expansion on day 2; further, stable pulmonary expansion was observed in these patients on days 4 and 6, respectively. However, the decision regarding additional video-assisted thoracoscopic surgery lay with the patients. Therefore, it remains unclear whether the closed thoracostomy was effective in treating pneumothorax in these patients. Nevertheless, if our results are regarded as successful based on the findings of complete pulmonary expansion, closed thoracostomy appears more effective than ambulatory treatment with the Heimlich valve.

The treatment period was also evaluated. Of the 20 patients who were successfully treated with the small-calibre catheter and Heimlich valve, 15 patients were weaned on day 6 and the remaining 5, on day 7. This was similar to the length of hospital stay in the control group, which was individually adjusted. Therefore, comparing the length of hospital stay between the two groups may not be useful. Nevertheless, ambulatory treatment was possible in the experimental group. Over a 6-month follow-up, recurrence occurred in 15% patients (3/20) in the experimental group and 8% patients (2/26) in the control group. Video-assisted thoracoscopic surgery was performed in 96% patients (26/27) with treatment failure in the experimental group and in 21 patients in the control group, including the five patients with persistent pneumothorax. Since the decision regarding video-assisted thoracoscopic surgery lay with patients in the control group, an inter-group analysis was not useful in this series. In some patients, the treatment outcome was assessed in the presence of underlying pulmonary tuberculosis. The success rate of treatment was 25% (1/4) in the experimental group and 50% (1/2) in the control group. No complications were encountered in the experimental group. However, the complications in the control group included haemothorax in two patients, subcutaneous emphysema in seven and pleural effusion in two patients. The medical expenses were approximately \#8364;340–420 per patient in the experimental group and \#8364;1200–1340 per patient in the control group; in other words, the treatment cost in the former was one-third of that in the latter. However, the medical expenses were \#8364;1420–1500 per patient in those who underwent closed thoracostomy after failure of treatment with the small-calibre catheter and Heimlich valve (Table 2 ).


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  		Table 2 Comparison of outcome between the two groups.
 
No differences were observed with regard to age, sex, onset time, major symptoms and size of pneumothorax between patients with successful treatment and those with treatment failure with the small-calibre catheter and Heimlich valve. However, the success rate was 53% when treatment was accomplished by inserting the catheter through the fifth intercostal space in the anterior axillary line and 24% in the case of second intercostal space in the midclavicular line (Table 3 ).


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  		Table 3 Comparison between patients with successful treatment and those with treatment failure with the small-calibre catheter and Heimlich valve according to clinical characteristics
 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
References
 
The Heimlich valve was developed by Henry Heimlich in 1966. Since 1968, the Heimlich valve has been used in the clinical setting in emergency care or inpatient treatment after chest surgery [4]. In addition, several studies have shown that the use of the Heimlich valve not only increased the success rate of pneumothorax treatment but also facilitated ambulatory treatment due to the lower complications rate [5]. However, the use of the Heimlich valve is negligible in a clinical setting, and only closed thoracostomy is available at many hospitals. This has raised issues such as overcrowding in emergency departments, patient discomfort and high medical expenses. Under these circumstances, we conducted this study to examine the success rate of pneumothorax treatment using the Heimlich valve; to identify the factors affecting the treatment outcomes; to evaluate whether the use of the Heimlich valve would facilitate ambulatory treatment possible; and to assess the effectiveness of such treatment in comparison with that of closed thoracostomy.

When the success rate of treatment was compared between the two groups, the success rate of the control group was twice that of the experimental group. Our results were not similar to those of other studies. The reasons for this are presumed to be as follows. First, catheters of higher calibre (10–16 F) were used and the length of hospital stay was longer in the other studies [6,7]. It has been reported previously that the rate of air removal greatly depends on the diameter of catheter [8]. Therefore, the lumen of the catheter used in our study may be considered insufficient for air removal from the bleb. Accordingly, a catheter with a larger diameter should be used in cases in which a large amount of air has to be removed. Second, another factor that could be presumed to have contributed to the difference in the success rate is that unlikely the use of a 7–8 F catheter with a high success rate of 84.5% in other studies [9,10], we directly performed closed thoracostomy without waiting to signs of improvement when the chest X-ray showed an increase in pneumothorax; this was done to avoid patient dissatisfaction.

In our study, blebs were identified in all the 26 patients who underwent video-assisted thoracoscopic surgery after the treatment using a small-calibre catheter and Heimlich valve had failed. This implies that it may be inappropriate to treat patients with blebs by using a small-caliber cathetre and Heimlich valve. However, this could not be determined because the successes and failure rates of treatment with a small-calibre catheter and Heimlich valve have not been compared thus far. Furthermore, subpleural blebs and bullae are found at thoracoscopy in up to 90% primary pneumothorax cases. Therefore, further studies are warranted to verify this.

The recurrence rate was 15% (3/20) in patients who underwent the treatment using a small-calibre catheter and Heimlich valve and 8% (2/26) in those who underwent closed thoracostomy. However, it was difficult to compare the experimental group and the control group with regard to the recurrence rate because the 26 patients who underwent closed thoracostomy were evaluated in comparison with only patients in whom the treatment was successful and surgery was not performed. No complications were noted in the patients who were treated using a small-calibre catheter and Heimlich valve; thus, this treatment yields more favorable results than closed thoracostomy. In addition, we did not encounter tension pneumothorax caused due to kinking or reverse connection of the Heimlich valve, as was reported in other studies [11,12]. The Heimlich valve was found to be safe, as described in many reports [11–13]. In patients who underwent closed thoracostomy, 11 patients developed complications, including haemothorax, subcutaneous emphysema and pleural effusion. However, these complications were treated with no further serious events. The use of the Heimlich valve is an advantageous over closed thoracostomy because it facilitates ambulatory treatment while decreasing the medical expenses.

No differences were observed with regard to age, sex, onset time, major symptoms and size of pneumothorax between patients with successful treatment and those with treatment failure with the small-calibre catheter and Heimlich valve. On the other hand, the success rate was higher when the catheter was inserted into the fifth intercostal space in the anterior axillary line than when it was inserted into the second intercostal space in the midclavicular line; however, the reasons for this difference are unknown. The above results might have been obtained because the emergency physician was accustomed to inserting the catheter into the fifth intercostal space.

Unfortunately, this study was associated with the following limitations. First, any increase in the size of pneumothorax during the observation period in outpatient treatment was directly judged as a failure without waiting for signs of improvement, and a closed thoracostomy was performed with hospitalization thereafter. This practice is considered to have increased the failure rate of the treatment using the small-calibre catheter and Heimlich valve to some extent. Second, the emergency physician was not accustomed to inserting the catheter into the second intercostal space; this could have contributed to the increase in the failure rate. Third, the number of patients with underlying disease was small; therefore, such patients could not be studied in detail.

Treatment of pneumothorax with a small-calibre catheter and Heimlich valve on an outpatient basis is considered inappropriate to some extent because its success rate is low, and continuous observation of the progress is not possible. Therefore, such treatment would be useful for only those physicians who are not accustomed to performing closed thoracostomy. Therefore, when a physician intends to employ this treatment modality due to its simplicity and absence of complications, the patients should be fully informed in advance regarding its success rate and of the possibility of requiring closed thoracostomy in the event of treatment failure.

In conclusion, the results of our study indicate that the use of an 8 F catheter and Heimlich valve is a treatment option for the ambulatory management of pneumothorax because it is inexpensive, is not associated with complications and is easy to use. However, the patients should be informed of its high failure rate prior to application.


   Acknowledgments
 
We thank Mrs Myeong-hee Jung for carefully reading the manuscript and correcting the language.


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 

  1. Baumann MH, Noppen M. Invited review series: pleural diseases Pneumothorax. Respirology 2004;9:157-164.[CrossRef][Medline]
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  3. Rhea JT, DeLuca SA, Greene RE. Determining the size of the pneumothorax in the upright patient. Radiology 1982;144:733-736.[Abstract/Free Full Text]
  4. Cannon WB, Mark JB, Jamplis RW. Pneumothorax: A therapeutic update. Am J Surg 1981;142:26-29.[CrossRef][Medline]
  5. Conces Jr. DJ, Tarver RD, Gray WG, Pearcy EA. Treatment of pneumothoraces utilizing small caliber chest tubes. Chest 1988;94:55-57.[Abstract/Free Full Text]
  6. Campisi P, Voitk AJ. Outpatient treatment of spontaneous pneumothorax in a community hospital using a heimlich flutter valve: a case series. J Emerg Med 1997;15:115-119.[CrossRef][Medline]
  7. Ponn RB, Silverman HJ, Federico JA. Outpatient chest tube management. Ann thorac Surg 1997;64:1437-1440.[Abstract/Free Full Text]
  8. Baumann MH, Strange C. Treatment of spontaneous pneumothorax: a more aggressive approach?. Chest 1997;112:789-804.[Free Full Text]
  9. Plaza V, Serra-Batles J, Lucas M, Palomares A, Brugues J. Effectiveness of the treatment of spontaneous pneumothorax using small caliber pleural catheter. Med Clin (Barc) 1994;103:46-48.[Medline]
  10. Miami H, Saka H, Horio Y, Iwahara T, Nomura T, Nomura F, Sakai S, Shimokata K. Small caliber catheter drainage for spontaneous pneumothorax. Am J Med Sci 1992;304:345-347.[CrossRef][Medline]
  11. Crocker HL, Ruffin RE. Patient-induced complications of a Heimlich flutter valve. Chest 1998;113:838-839.[Abstract/Free Full Text]
  12. Spouge AR, Thomas HA. Tension pneumothorax after reversal of a Heimlich valve. AJR 1992;158:763-764.[Free Full Text]
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This Article
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