Role of Simple Needle Aspiration in the Management of Pneumothorax

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1 ORIGINAL ARTICLE Role of Simple Needle Aspiration in the Management of Pneumothorax Shoaib Faruqi, Dheeraj Gupta, Ashutosh N. Aggarwal and Surinder K. Jindal Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India ABSTRACT Objectives. To determine the role of simple needle aspiration in the management of pneumothorax. Design. All patients presenting with a pneumothorax requiring intervention were included in this prospective study. Patients who were very sick or had tension pneumothorax were treated with direct intercostal chest tube drainage (ICTD) and others were subjected to simple aspiration. The procedure was deemed successful, if after aspiration the lung expanded completely or symptoms were relieved with residual pneumothorax of less than 15% of hemithorax. In case of failed aspiration ICTD was carried out. Results. Fifty-seven patients with 59 pneumothoraces were included in the study. Of these, 24 were treated with direct ICTD; 35 (12 spontaneous, 11 secondary and 12 iatrogenic pneumothoraces) were subjected to simple aspiration. Ten (83.3%) of the primary, 1 (9.6%) of the secondary and 11 (91.7%) of the iatrogenic pneumothoraces responded to simple aspiration. There were no significant complications. The pain perceived and the duration of hospital stay was significantly lesser in the simple aspiration group. Conclusions. Simple aspiration should be the initial modality of treatment for primary spontaneous and iatrogenic pneumothoraces. For secondary spontaneous pneumothorax and in conditions where pleurodesis is indicated, ICTD remains the treatment of choice. Key words: Pneumothorax, Primary spontaneous pneumothorax, Secondary spontaneous pneumothorax, Iatrogenic pneumothorax, Treatment, Simple aspiration. [Indian J Chest Dis Allied Sci 2004; 46 : ] INTRODUCTION Pneumothorax, defined as the presence of air in the pleural cavity 1, can be classified as spontaneous, which occurs without any preceding event, and traumatic. Spontaneous pneumothorax can be subdivided into primary spontaneous and secondary spontaneous pneumothorax. Secondary spontaneous pneumothorax is associated with an underlying lung pathology 2,3. With the advent of increasing diagnostic and therapeutic procedures iatrogenic pneumothorax is becoming very common 4. Regardless of the aetiology, the aim of treatment of pneumothorax is to eliminate the collection of air from the pleural cavity. Invasive [Received: April 30, 2003; accepted after revision: August 26, 2003] Correspondence and reprints request: Dr S.K. Jindal, Professor and Head, Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh , India; Tele.: (Extn. 6821); Telefax: ; <skjindal@indiachest.org>.

2 184 Needle Aspiration in the Management of Pneumothorax S. Faruqi et al techniques are required if the pneumothorax occupies greater than 15% of the involved hemithorax, is progressive over time, or, if the patient is symptomatic. The insertion of an intercostal chest tube drainage (ICTD) is the most commonly used treatment modality for pneumothorax but requires significant expertise and hospitalization. Needle aspiration provides a simple and easy alternative that can be performed on out-patient basis 5,6. The procedure has been recommended for initial management of symptomatic spontaneous pneumothorax by the British Thoracic Society 7. The American College of Chest Physicians guidelines for management of pneumothorax did not recommend simple aspiration for any type of pneumothorax 8 ; a suggestion that has been questioned 9. This study is aimed at determining the efficacy of simple needle aspiration for treatment of pneumothorax. MATERIAL AND METHODS All patients presenting to the department of Pulmonary Medicine for the treatment of pneumothorax requiring drainage (pneumothorax of a size > 15% of involved hemithorax or if the patient is symptomatic) during the period of January 2001 and May 2002 were included in the study. Very sick patients and those with tension pneumothorax were excluded from the study. Clinical and demographic details were recorded for each patient and a baseline chest radiograph was obtained. Other laboratory investigations that were performed included haematological, biochemical parameters and coagulation profile. Irrespective of the aetiology of the pneumothorax, all the patients were managed with simple aspiration as the initial treatment modality. A repeat chest radiograph was obtained after four hours. The procedure was deemed successful if there was (i) complete re-expansion of the lung; or (ii) less than 15% pneumothorax remained and the patient was relieved of the symptoms. In case simple aspiration failed, the patient was managed with ICTD or one repeat aspiration as per the suggested algorithm (Figure 1). The Institute Ethics Committee had cleared the study, and informed consent was obtained from all patients prior to inclusion into the study. The procedure was performed following strict aseptic precautions with the patient lying down in the supine position. The aspiration was carried out in the second inter-costal space in the mid-clavicular line or the fourth inter-costal space in the anterior axillary line. The site was infiltrated with lignocaine. An 18 G intravenous (IV) cannula was inserted into the pleural cavity. The needle was withdrawn and three-way stopcock was connected to the IV cannula. A 50 cc syringe and IV tubing with its end under water seal were connected to the cannula through the three-way stopcock. Air was aspirated and expelled by means of the IV tubing. The amount of air aspirated was noted. The end point of the procedure was a feeling of resistance to aspiration or if the patient began cough excessively. The IV cannula was withdrawn and the entry site was sealed. ICTD insertion was done through the fourth intercostal space in the mid-axillary line. After infiltration with local anaesthetic agent, the skin was incised and the pleura exposed by means of blunt dissection of the fascia and the underlying muscles. A nick was made in the pleura and a 24G Portex chest tube was introduced into the pleural cavity through the track. The chest tube drain was connected to an underwater seal. No negative suction was applied. The outcome parameters included the success rate of the procedure as defined earlier and the need/duration of the hospital stay. Patient s comfort was evaluated using a visual analog scale (VAS) which was a 10 cm horizontal scale with 11 markings, from 0 to 10, 1 cm apart where 0 represented not much pain and patient felt very comfortable and 10 represented severe discomfort felt by the patient. Each patient was asked to mark the number on the scale, which approximated most with the perceived pain. The need for analgesia required during and after the procedure was also recorded. Success and partial success rates for simple aspiration were considered as the end points. Outcome parameters were compared among primary spontaneous pneumothorax,

3 2004; Vol. 46 The Indian Journal of Chest Diseases & Allied Sciences 185 Figure 1. Treatment protocol for patients suspected to have pneumothorax (ICTD: intercostal chest tube drainage). secondary spontaneous pneumothorax, and iatrogenic pneumothorax. RESULTS Fifty-nine episodes of pneumothorax in 57 patients were evaluated for inclusion in the study. Of these, 24 patients were treated with direct ICTD on an emergency basis. The remaining 33 patients had 35 episodes of pneumothorax, which were managed as per the protocol. For the purpose of analysis the episodes of pneumothorax were divided into the following four groups: (i) primary spontaneous pneumothorax (PSP, n=12); (ii) secondary spontaneous pneumothorax (SSP, n=11); (iii) iatrogenic pneumothorax (IP, n=12) and (iv) those requiring direct ICTD (DI, n=24). The demographic characteristics of the various groups are summarized in table 1. In the IP group, the mean age as well as the proportion of female patients were higher as compared to spontaneous pneumothorax group. In the other groups the age and sex distribution were comparable. Patients with spontaneous pneumothorax most often presented with breathlessness (93%), chest pain (83%) and cough (41%). History of exertion at the onset of symptoms was noticed in four cases (6.7%). A definite family history of

4 186 Needle Aspiration in the Management of Pneumothorax S. Faruqi et al Table 1. Demographic profile of the study group PSP SSP IP DI Total No. of cases Male Female Age (years) Mean Range Side of pneumothorax Right : Left 5 : 7 7 : 4 8 : 4 16 : 8 36 : 33 Size of pneumothorax (% hemithorax) Mean Range PSS: primary spontaneous pneumothorax; SSP: secondary spontaneous pneumothorax; IP : iatrogenic pneumothorax; DI : direct intercostal chest tube drainage group. pneumothorax could not be elicited in any of the patients. Four of the 11 cases with SSP had underlying pulmonary tuberculosis (PTB), five had chronic obstructive pulmonary disease (COPD), one patient had both COPD and PTB; and one patient had Pneumocystis carinii pneumonia. Of the 12 patients with IP, six were secondary to transbronchial lung biopsy (TBLB). Three of these patients had suspected interstitial lung disease, two had PTB and one had bronchogenic carcinoma. Three cases with IP were the result of subclavian line insertion; two patients developed IP following attempted pleurocentesis, and in one patient IP developed following an attempt at computerised tomographic scan (CT scan) guided fine needle aspiration. There were 24 patients who required direct ICTD. Of these, four patients had tension pneumothorax, eight patients (33%) had a second or subsequent recurrence of pneumothorax and majority (n=18, 75%) had secondary pneumothoraces. Fourteen patients required pleurodesis. The response to simple needle aspiration was different with respect to aetiology of the pneumothorax, with success rates in PSP (10 of 12, 83.3%) and IP (11 of 12, 91.7%) being much higher than in SSP (one of 11, 9.6%; p<0.01). The age, sex, and size of pneumothorax did not have any bearing on the outcome of simple needle aspiration. The amount of air aspirated in patients with PSP (mean 1213 ml, range ml), SSP (mean 1554 ml, range ml) and IP (mean 680 ml, range ml) were similar. Overall success rate for simple needle aspiration was thus 62.9% (22/35 patients). Amongst the patients with PSP, two had recurrent pneumothorax. The first was a 21- year-old male patient who had a right-sided (60%) pneumothorax that was aspirated successfully. Subsequently, six months later, he developed a 40% pneumothorax on the left side, which was again managed successfully by simple aspiration. The second was a 16-year-old male who was admitted for the treatment of deep venous thrombosis who developed a 60% left-sided PSP which was managed successfully by simple aspiration performed twice. A month later, he developed a right-sided 50% PSP which again responded to simple aspiration. Both patients had remained well on follow-up at six months. Of the two patients who did not respond to simple aspiration, one was a 16-year-old male patient with a symptomatic left-sided 30% pneumothorax. He responded to simple aspiration initially, but had a recurrence within 24 hours and needed ICTD. The other was a 21- year-old male with a right-sided 50% pneumothorax, which did not respond to simple aspiration, and needed ICTD. Only one of the patients with IP, a 34-year-old female patient with a 40% right-sided pneumothorax

5 2004; Vol. 46 The Indian Journal of Chest Diseases & Allied Sciences 187 following subclavian line cannulation, did not respond to simple aspiration. The duration of hospital stay was lesser in the PSP and IP groups as compared to the SSP and DI groups (Table 2). It was seen that the mean duration of hospital stay in those pneumothoraces which responded to simple aspiration was 1.6 days as compared to 10 and 8.2 in the groups managed by ICTD after failed simple aspiration and direct ICTD respectively, (p<0.01). Similarly, the mean score of pain perceived on VAS in those successfully managed by simple aspiration alone was 1.6 as compared to 4.0 in those managed by direct ICTD and 4.2 in those who were managed by ICTD after failed simple needle aspiration (p<0.01). The duration of hospital stay and the pain perceived on the VAS were not significantly different in those managed by direct ICTD and those requiring ICTD after failed simple needle aspiration. All patients required local analgesia during the procedure. Post-procedure, none of the patients managed by simple needle aspiration required any further analgesia while those on requiring ICTD required frequent analgesics. The cost of the equipment needed for simple aspiration was approximately Rs. 90; while that of direct ICTD was Rs Three of the 35 patients (one with PSP, two with SSP) managed with simple needle aspiration developed minimal subcutaneous emphysema. All patients improved without any specific intervention. None of the patients developed clinical or radiological evidence of re-expansion pulmonary oedema. All the patients tolerated the procedure very well. DISCUSSION Role of simple needle aspiration in the management of pneumothorax has been debated for a long time. In 1966, Ruckley and Mc Cormack 3 condemned simple aspiration while in the same year Stradling and Poole 10 strongly put forward their views favouring conservative management. Consensus seems to be elusive even forty years later. We have observed a good outcome for simple needle aspiration in the present study. Recently, Morimoto et al 11 advocated thoracoscopic surgery for the first episode of PSP in young men whereas others have recommended simple aspiration as the initial treatment modality of choice for PSP. In a randomised prospective multi-centric pilot study in the management of first episode of PSP, 27 of the 60 patients were managed by simple aspiration and the rest were managed with chest tube drainage. The one week success rates were 93% and 85% and the recurrence rates at one year follow-up were 26% and 27.3% in the manual aspiration and chest tube drainage groups respectively 12. Simple aspiration has been described using several techniques such as catheters and Heimlich flutter valves. A simple IV cannula has also been used by various authors 5,7, The success rates for simple aspiration using an IV cannula in these studies for the different types of pneumothoraces are: PSP 55% to 100%; SSP Table 2. Duration of hospital stay and severity of pain on visual analogue scale in patients with pneumothorax PSP SSP IP DI Overall SA I-fSA Duration of hospital stay (days) Range Mean Pain of visual analogue scale (0-10) Range Mean PSP: primary spontaneous pneumothorax; SSP: secondary spontaneous pneumothorax; IP: iatrogenic pneumothorax; DI: direct intercostal chest tube drainage group; SA: simple aspiration successful; I-fSA: patients requiring chest tube drainage after failed simple aspiration.

6 188 Needle Aspiration in the Management of Pneumothorax S. Faruqi et al 35% to 63%; IP 67% to 100% and, overall spontaneous pneumothorax 51% to 80%. In the present study the corresponding success rates were: 83%, 8%, 48% and 92% respectively. While the success rates for PSP in the present study are in accordance with those described earlier, the technique was found to be of limited value in SSP. Little data are available in the literature regarding treatment for SSP. The lower success rate for simple aspiration in patients with SSP in the present study could be partly due to the differences in the underlying aetiology of SSP. PTB, the commonest cause of SSP (37%), appears to contribute to a poorer outcome. Few studies have evaluated simple aspiration using an IV cannula in the management of IP other than isolated case reports 17, 19. In a series comprising of twelve IPs of various aetiologies, a success rate of 67% was reported 19. Another Figure 2. Proposed algorithm for the management of pneumothorax (ICTD: intercostal chest tube drainage; PSP: primary spontaneous pneumothorax; SSP: secondary spontaneous pneumothorax; IP: iatrogenic pneumothorax).

7 2004; Vol. 46 The Indian Journal of Chest Diseases & Allied Sciences 189 study evaluation simple aspiration in the treatment of pneumothorax caused by CTguided biopsy, success rate of 71% was observed 17. In patients with IP, we have also observed an excellent response to simple aspiration with a high success rate of (11 of the 12, 91.7%). This is in contrast to the observation in patients with SSP who responded poorly to simple aspiration. The reason for better response observed with simple aspiration in patients with IP due to procedures such as TBLB, CT- guided FNAC and CVP line insertion could be due to the high index of clinical suspicion because of which small air leaks are identified and treated earlier. The success rate of all the kinds of pneumothoraces put together in this study was 60%. The duration of hospitalization required and cost incurred were lesser in those who responded to simple catheter aspiration versus those who required ICTD. The pain perceived on the VAS was lesser in those who responded to simple catheter aspiration. Complications were minimal. The only requirement for simple aspiration is observation for a period, which is less than 24 hours with no need for hospital admission. This is especially important in the Indian context where hospitals are rather over-burdened. Based on our findings, we have suggested an algorithm for the management of pneumothorax (Figure 2). The simplicity of the procedure, lack of complications, no requirement of expert medical facilities and minimal duration of hospital monitoring favour that simple needle aspiration should be the preferred treatment for PSP and IP. Even if the procedure fails ICTD can be inserted with in 24 hours. For SSP and for recurrent PSP where pleurodesis is indicated, direct ICTD remains the treatment of choice. REFERENCES 1. Light RW. Pleural Diseases, 4th ed. Baltimore: Williams and Wilkins; Smith WG, Rothwell PPG. Treatment of spontaneous pneumothorax. Thorax 1962; 17 : Ruckley CV, McCormack RJ. The management of spontaneous pneumothorax. Thorax 1966; 21 : Despars JA, Sassoon CS, Light RW, Significance of iatrogenic pneumothoraces. Chest 1994; 105 : Bevelaqua FA, Aranda C. Management of spontaneous pneumothorax with small lumen catheter manual aspiration. Chest 1982; 81 : Light RW, Broaddus VC. Pneumothorax. In : Murray JF, Nadel JA, eds Textbook of Respiratory Medicine; 3rd edn. Philadelphia: WB Saunders; 1994: Miller AC, Harvey JE Guidelines for the management of spontaneous pneumothorax. Standards of Care Committee, British Thoracic Society. BMJ 1993; 307 : Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous pneumothrax: An American College of Chest Physicians Delphi Consensus Statement. Chest 2001; 119 : Miller AC, Harvey JE. Pneumothorax: What s wrong with simple aspiration? Chest 2001; 120 : Stradling P, Poole G. Conservative management of spontaneous pneumothorax. Thorax 1966; 21 : Morimoto T, Fukai T, Koyama H, Noguchi Y, Shimob T. Optimal strategy for first episode of primary spontaneous pneumothorax in young men. A decision analysis. J Gen Intern Med 2002; 17 : Noppen M, Alexander P, Driesen P, Slabbynck H, Verstraeten A. Manual aspiration versus chest tube drainage in first episodes of primary spontaneous pneumothorax: A multicentric, prospective randomized pilot study. Am J Respir Crit Care Med 2002; 165 : Hamilton AA, Archer GL. Treatment of pneumothorax by simple aspiration. Thorax 1983; 38 : Raja OG, Lalor AJ. Simple aspiration of spontaneous pneumothorax. Br J Dis Chest 1981; 75 : Obeid F, Shapiro M, Richardson HH, Horst HM, Bivins BA. Catheter aspiration for simple pneumothorax (CASP) in the outpatient

8 190 Needle Aspiration in the Management of Pneumothorax S. Faruqi et al management of simple traumatic pneumothorax. J Trauma 1985; 25 : Andrivet P, Djedaini K, Teboud JL, Brochard L, Dreyfuss D. Spontaneous pneumothorax: comparison of thoracic drainage vs immediate or delayed needle aspiration. Chest 1995; 108: Yankelevitz DF, Davis SD, Henschke CI. Aspiration of large pneumothorax resulting from trans thoracic needle biopsy. Radiology 1996; 200 : Keily DG, Ansari S, Davey WA, Mahadevan V, Taylor GJ, Seaton D. Bedside tracer gas technique accurately predicts outcome in aspiration of pneumothorax. Thorax 2001; 56 : Markos J, McGonigle P, Phillips MJ, Pneumothorax: Treatment by small lumen catheter aspiration. Aust NZ J Med 1990; 20 : RADIOLOGY FORU UM It is proposed to extend the scope of the Radiology Forum of our Journal by inviting our readers as well as other workers in the field or Respiratory Medicine to submit brief report of patients with interesting clinical and radiological features for publication.these will be published, provided that : (a) the condition is of sufficient clinical and radiological interest; (b) photographs (10 cm 8 cm) are of excellent quality for printing (Maximum : 3 photographs); (c) the diagnosis in each case has been confirmed; (d) the chest radiograph is accompanied by brief clinical account, not exceeding one page typescript. All the material received for publication in the Radiology Foru m will be evaluated to judge the suitability for publication by our experts panel. Editor-in-Chief