Pneumothorax Doesn’t Always Require Admission

Background
Percutaneous needle biopsy is the most commonly used method of evaluating for malignancy in lung lesions. This procedure is relatively noninvasive. Outpatient management of pneumothoraces using a Heimlich valve and small-caliber chest tube has been reported as successful in the surgical literature.

The objective of a recent study was to determine the efficacy of outpatient management of post biopsy pneumothorax with small-caliber chest tubes attached to a Heimlich valve.

The study has concluded that treatment of post biopsy pneumothorax can be safely and effectively performed in an outpatient setting using small-caliber chest tubes attached to a Heimlich valve.

Methodology
In this retrospective review, data were analyzed to determine if there were any characteristics of the patient, lesion, or technique used that influenced outcome. The biopsy and pneumothorax treatment algorithm was as follows:

• All patients had lung biopsies under CT guidance using a 22-gauge needle through an 18-gauge guide needle. A 200-gauge core biopsy was taken, if necessary, through this guide needle. The patient underwent chest x-ray 30 minutes post procedure, and again after three hours if no pneumothorax was seen on initial chest x-ray.
• If the patient developed a large pneumothorax (>30% of intrathoracic volume) or became symptomatic at any time, an 8.5-F small-caliber chest tube was placed in the second anterior intercostal space, which was attached to a Heimlich valve. Once patients had full re-expansion of the lung, they were sent home.

• If re-expansion was not attained, they were admitted and placed on wall suction via a chest drain. Outpatients returned the next day and had the chest tube clamped for two hours prior to undergoing chest x-ray.

Results
423 patients (45%) had a pneumothorax after biopsy. Only 191 biopsy patients (20.5%) required a chest tube to be placed for management of the pneumothorax; of these, 178 (93.2%) were successfully treated as outpatients. Of these 178 patients, 146 had the chest tube removed the next day without sequelae. The remaining outpatients had their chest tubes removed in two to 10 days. One patient developed a hemothorax.

Reviewer’s Comments
Of all patients who needed chest tubes to treat their pneumothorax, about 24% needed prolonged chest tube drainage and/or additional interventions.

Several factors were analyzed for each case: lesion size and location, length of the needle path through aerated lung, number of visceral pleural layers punctured, total number of punctures, and presence of emphysema in the path of the needle.

The only factor that seemed to be a positive predictor of additional interventions and/or hospital admissions was presence of emphysema in the needle path.

Author: Sharon Gonzales, MD

Reference
Gupta S, Hicks ME, et al. Outpatient Management of Postbiopsy Pneumothorax With Small-Caliber Chest Tubes: Factors Affecting the Need for Prolonged Drainage and Additional Interventions. Cardiovasc Intervent Radiol; 2008; 31 (March-April): 342-348: