Online supplement
Management of primary spontaneous pneumothorax by intensivists: an international survey.
Damien Contou1,2, MD; Fréderic Schlemmer3, MD, PhD; Bernard Maitre3, MD, PhD; Keyvan Razazi1,2, MD; Guillaume Carteaux1,2, MD, PhD; Armand Mekontso Dessap1,2, MD, PhD and Nicolas de Prost1,2, MD, PhD.
eTable 1. Results of the ESICM-endorsed self-administered questionnaire.
Items of the questionnaire / N / %Type of institution
University hospital
Public hospital
Private Hospital / 104/178
62/178
12/178 / 58
35
7
Type of ICU
Mixed
Medical
Respiratory
Surgical
Neurological
Cardiac
Other / 105/178
35/178
23/178
10/178
2/178
1/178
2/178 / 59
20
13
6
1
1
1
Number of admissions/year
<500
Between 500 and 1000
>1000 / 41/178
88/178
49/178 / 23
49
28
Number of beds
<15
Between 15 and 25
<25 / 68/178
84/178
26/178 / 38
47
13
Intermediate ICU
Yes
No / 104/178
74/178 / 58
42
Department of thoracic surgery
Yes
No / 97/178
81/178 / 54
46
Initial training (in addition to intensive care)
Pulmonologist
Anesthesiologist
Cardiologist
Nephrologist
Emergency specialist
Other / 57/178
49/178
8/178
6/178
11/178
47/178 / 32
28
4
3
6
26
Physician performing pleural drainage
Intensivists
Surgeon
Pulmonologist
Emergency specialist
Other / 99/172
29/172
28/172
14/172
2/172 / 58
17
16
8
1
Pleural drainage setting
Emergency department
ICU
Intermediate ICU
Operating room
Post-anesthesia care unit
In the wards / 32/172
67/172
45/172
7/172
6/172
15/172 / 19
39
26
4
3
9
Detailed management strategy in case 1a
Hospital discharge and observation
Hospitalization in the wards with high rate of oxygen flow
Needle aspiration
Small-bore chest drain insertion (<14 French) / 93/178
71/178
5/178
9/178 / 52
40
3
5
Detailed management strategy in case 2a
Hospital discharge and observation
Hospitalization in the wards with high rate of oxygen flow
Needle aspiration
Small-bore chest drain insertion (<14 French)
Large-bore chest drain insertion (≥14 French) / 8/178
31/178
30/178
96/178
13/178 / 4
17
17
54
7
Detailed management strategy in case 3a
Needle aspiration
Small-bore chest drain insertion (<14 French)
Large-bore chest drain insertion (≥14 French) / 12/178
116/178
50/178 / 7
65
28
Size of chest drain when pleural drainage is indicated
Central venous catheter (5 French)
12 French
14 French
16 French
18 French
20 French / 25/172
57/172
36/172
29/172
16/172
9/172 / 15
33
21
17
9
5
Timing of pleural suction
As soon as the chest drain is inserted
In case of incomplete lung re-expansion on a chest-X-ray at H24-H48 / 94/172
78/172 / 55
45
Have you ever observed a re-expansion pulmonary edema?
Yes
No / 112/172
60/172 / 65
35
Pleural ultrasonography to control lung re-expansion
Always
Sometimes
Never / 22/172
57/172
93/172 / 13
33
54
Timing of surgeon referral in case of persistent air leak
After 2 days
After 3 days
After 4 days
After 5 days
After 6 days / 57/171
41/171
38/171
25/171
10/171 / 33
24
22
15
6
Weaning strategy before chest-tube withdrawal
Clamp the drain for <12 hours
Clamp the drain for >12 hours
Stop pleural suctioning for <12 hours
Stop pleural suctioning for >12 hours
Withdraw the drain without clamping the chest-tube nor stopping pleural suction / 37/171
34/171
38/171
38/171
24/171 / 22
20
22
22
14
Indications of referral to a thoracic surgeon to prevent PSP recurrence
After a first episode of PSP
After a second episode of ipsilateral PSP
After a first episode if the PSP is bilateral
After a first episode in case of tension PSP
After a first episode of contralateral PSP
It depends on the patient’s profession / 18/178
130/178
98/178
20/178
86/178
72/178 / 10
73
55
11
48
40
ESICM, European Society for Intensive Care Medicine; ICU, intensive care unit; PSP, primary spontaneous pneumothorax; a see the clinical scenarios in the appendix
eTable 2. Randomized studies assessing the efficiency of needle aspiration (NA) versus pleural drainage (PD) for initial treatment of patients with primary spontaneous pneumothorax (adapted from [6])
First author / Harvey [1] / Andrivet [2] / Noppen [3] / Ayed [4] / Parlak [5]Year / 1994 / 1995 / 2002 / 2006 / 2012
Type of study / RCT / RCT / RCT / RCT / RCT
Number of patients / 73 / 61 / 60 / 137 / 56
Outcomes / Significant / Shorter hospital stay
in NA group / Higher rate
of success
in PD group / Lower rate of hospital admissions in NA group / - / -
Not significant / Recurrence rate at 1 year / Duration of hospital stay
Recurrence at 3 months / Immediate success
Success at
1 week
Recurrence
at 1 year / Immediate success
Success at
1 week
Recurrence at 1 year / Immediate success
Success at
2 weeks
Recurrence at 1 year
RCT, randomized controlled trial
Appendix: self-administered questionnaire available online.
Management of primary spontaneous pneumothorax in the ICU:
an international survey
This survey focuses on the management of patients with primary spontaneous pneumothorax breathing spontaneously.
1. In which country do you practice?
2. In which city?
3. What type of institution is your hospital?
o University hospital
o Public hospital
o Private hospital
Name of your institution: ______
Name of your department: ______
4. What type of ICU do you work in?
o Mixed ICU
o Medical ICU
o Surgical ICU
o Cardiac ICU
o Neurological ICU
o Other: ______
5. What is the approximate number of patients/year admitted to your ICU?
o < 500
o Between 500 and 1000
o > 1000
6. What is the number of beds in your ICU?
o < 25
o Between 15 and 25
o < 15
7. Do you have an intermediate ICU?
· Yes
· No
8. Do you have a department of thoracic surgery in your hospital?
· Yes
· No
9. What is your initial formation (in addition to intensive care)?
· Pulmonologist
· Cardiologist
· Nephrologist
· Neurologist
· Anesthesiologist
· Thoracic surgeon
· Emergency specialist
· Other
10. In case of a first episode of primary spontaneous pneumothorax in a young man without breathlessness, what would be your management strategy if the chest-X-ray were as follows?
· Needle aspiration
· Small-bore chest drain insertion (<14F)
· Large-bore chest drain insertion (>14F)
· Hospitalization in the wards with high rate of oxygen flow
· Hospital discharge and observation
11. Would you draw arterial blood gases (SpO2 94% and respiratory rate 16/min)?
· Yes
· No
12. Would you perform a thoracic tomodensitometry?
· Yes
· No
13. If the chest-X-ray were as follows, what would be your management strategy?
· Needle aspiration
· Small-bore chest drain insertion (<14F)
· Large-bore chest drain insertion (>14F)
· Hospitalization in the wards with high rate of oxygen flow
· Hospital discharge and observation
14. Would you draw arterial blood gases (SpO2 94% and respiratory rate 16/min)?
· Yes
· No
15. Would you perform a thoracic tomodensitometry?
· Yes
· No
16. If the chest-X-ray were as follows, what would be your management strategy?
· Needle aspiration
· Small-bore chest drain insertion (<14F)
· Large-bore chest drain insertion (>14F)
· Hospitalization in the wards with high rate of oxygen flow
· Hospital discharge and observation
17. Would you draw arterial blood gases (SpO2 94% and respiratory rate 16/min)?
· Yes
· No
18. Would you perform a thoracic tomodensitometry?
· Yes
· No
19. You have decided to insert a chest drain. In your institution, who would perform the procedure?
· A surgeon
· An emergency department physician
· An intensivist
· A pulmonologist
· Other
20. Where would the chest drain insertion procedure be performed?
· In the emergency department
· In the ICU
· In the intermediate ICU
· In the operating room
· In the postanesthesia care unit
· In the wards
21. What size of chest drain would you choose for managing the case presented above?
· Small-bore chest drain insertion (<14F)
· Large-bore chest drain insertion (>14F)
· Central venous catheter
22. What would be the timing of pleural suction initiation?
· As soon as the chest drain is inserted
· In case of incomplete re-expansion of the lung on the control chest-X-ray
· In case of incomplete re-expansion of the lung on a chest-X-ray at H48
· Never
23. If you decide to perform a pleural suction, what pressure level would you apply?
· -10 cmH2O
· -20 cmH20
· -30 cmH20
· -40 cmH20
24. Have you ever observed a re-expansion pulmonary edema?
· Yes
· No
· I don’t know
25. How often do you use chest echography to control lung re-expansion?
· Never
· Sometimes
· Always
26. A chest-X-ray shows that the left lung is re-expanded but there is a persistent continuous bubbling at H48. What is your strategy?
· I wait and see 48 more hours
· I insert a 2nd larger chest drain
· I consider surgical referral
· I decrease the level of pleural suction
· I increase the level of pleural suction
27. In case of persistent air leak or failure of the lung to re-expand, when do you usually consider referring the patient to a thoracic surgeon?
· After 2 days
· After 3 days
· After 4 days
· After 5 days
· After 6 days
28. A chest-X-ray now shows a complete re-expansion of the left lung and there is no more chest drain bubbling. How long do you maintain a pleural suctioning?
· < 6h
· Between 6 and 12h
· Between 12 and 24h
· >24h
29. You have decided to withdraw the chest drain. Before withdrawal, do you:
· Clamp the drain for <12h?
· Clamp the drain for >12h?
· Stop pleural suctioning for <12h?
· Stop pleural suctioning for >12h?
· Withdraw the drain without clamping the chest drain nor stopping pleural suctioning?
30. When do you usually refer your patient to a thoracic surgeon in order to prevent another episode of primary spontaneous pneumothorax (PSP)?
· After a first episode of PSP
· After a second episode of ipsilateral PSP
· After a third episode of ipsilateral PSP
· After a first episode if the PSP is bilateral
· After a first episode in case of tension PSP
· After a first episode in case contralateral PSP
· It depends on the patient’s profession
REFERENCES
1. Harvey J, Prescott RJ, (1994) Simple aspiration versus intercostal tube drainage for spontaneous pneumothorax in patients with normal lungs. British Thoracic Society Research Committee. BMJ 309: 1338-1339
2. Andrivet P, Djedaini K, Teboul JL, Brochard L, Dreyfuss D, (1995) Spontaneous pneumothorax. Comparison of thoracic drainage vs immediate or delayed needle aspiration. Chest 108: 335-339
3. Noppen M, Alexander P, Driesen P, Slabbynck H, Verstraeten A, (2002) Manual aspiration versus chest tube drainage in first episodes of primary spontaneous pneumothorax: a multicenter, prospective, randomized pilot study. Am J Respir Crit Care Med 165: 1240-1244.
4. Ayed AK, Chandrasekaran C, Sukumar M, (2006) Aspiration versus tube drainage in primary spontaneous pneumothorax: a randomised study. Eur Respir J 27: 477-482.
5. Parlak M, Uil SM, van den Berg JW, (2012) A prospective, randomised trial of pneumothorax therapy: manual aspiration versus conventional chest tube drainage. Respir Med 106: 1600-1605.
6. Tschopp JM, Bintcliffe O, Astoul P, Canalis E, Driesen P, Janssen J, Krasnik M, Maskell N, Van Schil P, Tonia T, Waller DA, Marquette CH, Cardillo G, (2015) ERS task force statement: diagnosis and treatment of primary spontaneous pneumothorax. Eur Respir J 46: 321-335
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