Outpatient Management of Large Pneumothorax

A guest post by Justin Mazzillo, a community doc in New Hampshire.
“Okay Mr. Smith now that your chest tube is in we’re going to go ahead and discharge you.  Just come back to the Emergency Department if you have any problems.”

That’s pretty much what these investigators set out to do…with a few minor differences. Instead of following the more common practice of aspirate and observe or place a chest tube and admit, the authors’ goal was to demonstrate that patients with large primary and secondary pneumothorax can be managed as outpatients with pigtail catheters. This prospective case series of 132 patients aimed to evaluate the success rate of outpatient management, as well as the one-year recurrence rate, pain medication use, safety and cost of this approach.

Patients who presented to this French hospital with large primary or secondary pneumothoraces had a pigtail catheter placed, were observed for two hours without a confirmatory chest radiograph and then discharged. Patients were seen in follow-up clinic on days 2 and 4 and admitted to the hospital on day 4 if the pneumothorax failed to resolve.

Of the 132 patients, 78% were managed entirely as outpatients. Patients with primary and secondary pneumothoraces had similar success rates, although the latter group was considerably smaller.  Two patients had mechanical catheter issues that were addressed as outpatients on their follow-up visit on day 2. The recurrence rate at one-year was 26%. The average cost of being managed as an outpatient in this study was $926 vs. $4,276 for the conventional inpatient approach.

This seems like an attractive and safe option as health care costs continue to skyrocket and more patients are managed in the ambulatory setting.  
“Ambulatory Management of Large Spontaneous Pneumothorax With Pigtail Catheters”


8 thoughts on “Outpatient Management of Large Pneumothorax”

  1. A couple of years ago we had a patient walk into our ED with a chest tube in situ connected to a Heimlich valve, asking for removal. Turns out he had experienced a large spontaneous pneumothorax while in France but had plans to fly home to the US a day or two later, so they set him up as described, sent him on his way, and said to just go to the local emergency back home for confirmation of resolution and tube removal.

    The local staff, used to admitting EVERY significant pneumo, was in amazement that anyone would do something so crazy and a little confused for who to contact about removing the tube (what CT surgeon ever wants someone else's patient, especially when that someone else is across the Atlantic).

    Eventually it all got sorted out and the patient did fine, but thanks to FOAM I was pretty aware that they were doing this kind of stuff elsewhere. It's nice to see it finally gaining some traction in the literature.

  2. A couple of years ago we had a patient walk into our ED with a chest tube in situ connected to a Heimlich valve, asking for removal. Turns out he had experienced a large spontaneous pneumothorax while in France but had plans to fly home to the US a day or two later, so they set him up as described, sent him on his way, and said to just go to the local emergency back home for confirmation of resolution and tube removal.

    The local staff, used to admitting EVERY significant pneumo, was in amazement that anyone would do something so crazy and a little confused for who to contact about removing the tube (what CT surgeon ever wants someone else's patient, especially when that someone else is across the Atlantic).

    Eventually it all got sorted out and the patient did fine, but thanks to FOAM I was pretty aware that they were doing this kind of stuff elsewhere. It's nice to see it finally gaining some traction in the literature.

  3. Also being done in the great white north of Ottawa, Canada (with excellent f/u by our thoracic surgeons). Pigtails are much more comfortable and better tolerated by the patients.

  4. Also being done in the great white north of Ottawa, Canada (with excellent f/u by our thoracic surgeons). Pigtails are much more comfortable and better tolerated by the patients.

  5. Even better, currently a multicentre RCT is being run in Aus looking at expectant vs interventional approach for managing moderate-large sized primary spontaneous pneumothorax.

  6. Even better, currently a multicentre RCT is being run in Aus looking at expectant vs interventional approach for managing moderate-large sized primary spontaneous pneumothorax.

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