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Mazen Al-Alawi,Abirami Subramaniam,R Khan,E Moloney,SJ Lane
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Ir Med J. 2013 Feb;106(2):62
Sir
Laennec first defined air in the pleural cavity as a pneumothorax in 1819. Spontaneous pneumothoraces are defined as primary or secondary depending on the presence or absence of interstitial lung disease. The British Thoracic Society (BTS) initially published guidelines for the management of pneumothoraces in 1993. Updated guidelines were published in 2010 in an effort to reinforce the trend in safer and minimally invasive management strategies1. The inclusion of algorithms reinforced compliance with guidelines and provided easy-to-use templates to guide the management of pneumothoraces. The experience at our local hospital was highlighted through an initial audit that identified the need to formally adopt BTS guidelines, thereby establishing a more standardized practice and improve management of spontaneous pneumothoraces2. A retrospective re-audit of primary spontaneous pneumothorax management according to the BTS guidelines following interventions to improve dissemination of guidelines at the hospital included presentation at national meetings and grand rounds.
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A case note review was performed on all patients seen at Tallaght Hospital between January 2008 and June 2011 and identified through an electronic enquiry database to contain the code primary spontaneous pneumothorax (PSP). 46 cases of PSP were identified with a mean age at presentation of 32.2(±11.2) years. 36(78%) patients were male. 17(37%) cases of small and symptomatic PSP required intervention. 6(35%) had an attempted manual aspiration and 5(60%) required a chest drain following failed aspiration. There were 29(63%) large PSP cases however only 7(24%) had an attempted manual aspiration in accordance with BTS guidelines. The mean duration of admission was 4.8 and 4.0 days for small and large PSP respectively.
The findings from this audit identified a degree of divergence from the BTS guidelines. This may be explained through lack of awareness or access to the guidelines. However the degree of compliance within our local hospital is in keeping with previous studies that identified uptake levels of 20-40% among non-respiratory and A&E staff. The re-audit highlighted a continued trend towards a more conservative approach to the management of spontaneous PSPs with increased uptake in the use of supplemental oxygen from 14% to 53% at the re-audit, and pleural aspiration from 7% to 35%. The use of oxygen in the management of pneumothoraces should be considered in the majority of patients as therapy will correct hypoxaemia and increase the rate of resolution. The study also highlighted the poor uptake of needle aspiration as a therapeutic tool in management of PSP despite evidence that it is as effective as large-bore chest drain insertion3. Mendis et al. highlighted a potential perception by clinicians that aspiration may be futile in the presence of a large pneumothorax4. An alternative explanation may be that doctors lack the familiarity and training to confidently perform manual aspiration. Presentation of the audit at a national meeting, grand rounds, and publication failed to improve outcome measures. These findings highlight that the initial interventions were suboptimal in an environment with a high turnover of doctors in training between departments and specialties. Improved outcomes in pneumothorax management may require a proforma to improve record keeping or a dedicated pneumothorax care pathway that includes an online step-by-step guide.
M Al-Alawi, A Subramaniam, R Khan, E Moloney, SJ Lane
Department of Respiratory Medicine, AMNCH, Tallaght, Dublin 24
Email: [email protected]
Acknowledgements
We extend our thanks to the staff of the IT and Medical Records Departments at Tallaght Hospital.
References
1. MacDuff A, Arnold A, Harvey J, Group BTSPDG. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010 Aug;65 Suppl 2:ii18-31.
2. Pallin M, Open M, Moloney E, Lane SJ. Spontaneous pneumothorax management. Ir Med J. 2010 Oct;103:272-5.
3. Ayed AK, Chandrasekaran C, Sukumar M. Aspiration versus tube drainage in primary spontaneous pneumothorax: a randomised study. Eur Respir J. 2006 Mar;27:477-82.
4. Mendis D, El-Shanawany T, Mathur A, Redington AE. Management of spontaneous pneumothorax: are British Thoracic Society guidelines being followed? Postgrad Med J. 2002 Feb;78:80-4.
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Author's Correspondence
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No Author Comments
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Acknowledgement
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No Acknowledgement
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Other References
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No Other References
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