Vol. 6 • Issue 8
• Page 24
An extremely healthy, active 16-year-old boy returned home from preseason baseball practice with right-sided chest pain. The pain was located in his right anterior chest, did not radiate and was pleuritic in nature. He denied any trauma to his chest or any previous episode similar to this. The pain began acutely and failed to respond with rest.
The teen was right-hand dominant. He was in good physical condition, with the exception of a minor upper-respiratory infection the previous week. He had no fever, chills or coughing. He had a benign medical history, and his family history was noncontributory.
My initial examination at his home revealed him to be in some discomfort as a result of his chest pain. He was unable to talk in long sentences because of his dyspnea. He appeared to be uncomfortable but not in any major distress. He had no cyanosis. He was slightly tachypneic, with a rate of 24 breaths per minute. He was slightly tachycardic at 100 beats per minute.
Examination of his heart revealed normal S1 and S2 rhythm. There were no murmurs, gallops or rubs. Examination of his lungs revealed decreased breath sounds on the right side compared with the left. He had increased egobronchophony and whispered pectoriliquoy on the right side compared with the left.
A spontaneous pneumothorax diagnosis was made. After obtaining a referral from his pediatrician, the teenager was seen in the emergency department. Chest X-ray confirmed a 25% right-sided pneumothorax. Surgical consultation was obtained.
Although the teenager's condition-pneumothorax-is common, the treatment method we chose was not conventional. The patient and his family were given the option for outpatient treatment with a small-bore catheter attached to a thoracic vent versus hospitalization with placement of a chest tube and the inherent limitations on his physical activity.
The patient was treated with a pleural catheter (thoracic vent) instead of chest tube thoracostomy. The patient was an athlete who was interested in a treatment that was effective, was uncomplicated and had the shortest recovery time so that his health would be optimized.
The patient had successful treatment with the pleural catheter and returned to school with the catheter in place on the second day after occurrence of the pneumothorax. Prior to removal of the catheter, chest X-ray showed complete resolution of the pneumothorax. Chest X-ray following removal of the catheter also showed complete lung expansion. He had the catheter a total of 5 days and had no complications from the procedure. He was able to return to baseball 3 weeks after the episode and has been playing without recurrent problems.
Spontaneous pneumothorax is a common entity with approximately 20,000 new cases identified each year in the United States.1Conventional therapy for pneumothorax consists of tube thoracostomy.2However, this treatment results in decreased patient mobility and is associated with substantial discomfort.2Pleural catheter placements are not a new entity, but recent literature suggests that they may be making a comeback in the treatment of spontaneous pneumothorax. Currently, many physicians are not confident in the use of small-bore catheters for the management of pneumothorax and use these catheters in a minority of patients.3Guidelines for the use of these catheters are not entirely clear. Some surgeons allow the size of the pneumothorax to dictate whether the small-bore catheters are an appropriate option. Some investigators believe that the choice between a small-bore catheter and standard chest tube is of minor importance if the patient is hospitalized for other reasons.4For the stable patient with spontaneous pneumothorax, small-bore catheterization is an option that may prove to be advantageous.
Roeggla and colleagues performed a cost analysis of standard chest tube therapy versus outpatient thoracic vent drainage.5The researchers found that the median length of hospitalization was 144 hours for patients receiving chest tubes at a cost of $6,160, versus a median 5-hour hospitalization and a cost of $500 for thoracic vent drainage. During this study, patients had an 84% success rate with the thoracic vent drainage versus 85% success rate of the conventional thoracic drainage.
The thoracic vent consists of a polyurethane catheter connected to a plastic chamber containing a one-way valve. There is no need to connect the drain to an underwater seal device, permitting this method to be employed for outpatient therapy.5The patient can remain mobile, although patients must be careful to keep the thoracic vent from dislodging.
Contraindications to vent placement include hydropneumothorax, hemopneumothorax, tension pneumothorax and the use of positive pressure ventilatory support.2Vents are inserted in the second intercostal space in the midclavicular line under local anesthesia. Chest X-rays are taken immediately after vent placement and daily thereafter to monitor re-expansion of the affected lung. The vent is removed when there is no fluctuation of the signal diaphragm with cough or respiration and there is evidence of complete resolution of the pneumothorax.
The advantage of the thoracic vent compared with simple needle aspiration is that the catheter remaining in place can continue to effect lung re-expansion, as opposed to a one-time event of simple aspiration.6It seems that the thoracic vent, like the simple needle aspiration, has the advantage of being cost effective. But the thoracic vent offers the further advantage of continued vent drainage that previously was only offered under conventional chest-tube drainage.
The goals of pneumothorax therapy are to eliminate intrapleural air collection, to facilitate pleural healing and to attempt to prevent recurrence of the pneumothorax. The rate of vent failure is higher among patients with spontaneous pneumothorax (as opposed to iatrogenic pneumothorax) and among patients with a total collapse as compared to patients with a partial loss of lung volume.2In the age of cost containment without sacrificing patient outcome, thoracic vent drainage can be considered an option for a patient with a spontaneous pneumothorax. The rate of success for treatment using this technique approaches the success of the conventional chest tube with the advantage of the thoracic vent being more convenient and less cumbersome than the traditional chest thoracostomy tube placement. This is one area that patients and insurers will find as an acceptable alternative.
Spontaneous pneumothorax can occur without an obvious preceding cause but can also be a complication of athletic activity. Pneumothorax has been reported in association with several sports, including scuba diving, weight lifting and even jogging.7Clinicians need to maintain a high index of suspicion for athletes presenting with chest pain and dyspnea and need to know what treatment options are available.
Christine H. Bruce is the director of the physician assistant program at Allentown College of St. Francis de Sales in Center Valley, Pa.
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