HOSPITAL GUIDELINE PRIMARY SPONTANEOUS PNEUMOTHORAX (PSP) Aim: To provide a consistent approach to PSP emphasizing shared decision making and consistent communication. NOTE 1 PATIENT PSP features: Clinical diagnosis: • 10 yrs of age or older pneumothorax (PNX) • Tall / thin habitus • No prior hx of lung disease 1. Oxygen • No active lung disease 2. Chest tube insertion Further Features PSP? Acutely short • No recent chest trauma No Yes Yes 3. –20cm suction evaluation (See note 1) of breath? • CXR normal apart from PNX 4. Pain control • Male predominance 5. Family brochure No CT of chest is NOT recommended Air leak unless diagnosis Assess PNX Yes No of PSP is unclear. laterality and size >3 days? Surgical SHARED DECISION MAKING Bilateral PNX <20% Unilateral PNX* >20% Unilateral PNX pleurodesis Considerations: 1. Discharge home with f/u Oxygen, pain relief Oxygen, pain relief Oxygen, pain relief in 1–2 weeks SHARED DECISION MAKING SHARED DECISION MAKING SHARED DECISION MAKING 2. Surgical Considerations: Considerations: Considerations: pleurodesis 1. Strongly consider at least 1. Discharge, f/u in 24 hrs 1. Chest tube; -20cm sxn unilateral surgical pleurodesis 2. Brief SSU or overnight 2. Surgical pleurodesis 2. Bilateral intervention per observation per patient lifestyle Post-operative surgical care patient lifestyle and family 3. If this is a recurrence, and family preference • Analgesia: hydromorphone, PCA 0.005 mg/ preference surgical pleurodesis 3. If this is a recurrence, kg/dose Q 30 min prn to a maximum of surgical pleurodesis 0.01 mg/kg/hr or 1 mg/hr; no infusion • Acetaminophen: 10–15 mg/kg IV Q6hrs scheduled for the first 24 hrs then Q 6 hrs prn Recurrence after observation: chest tube placement and/or surgical • Incentive spirometry Q 1 hr while awake pleurodesis, depending on patient lifestyle or family preference Air leak persists >3 days: surgical pleurodesis; • Chest tube to -20cm suction until air leak air leak resolves <3 days: discharge to home or surgical pleurodesis per patient lifestyle and resolves and pleural fluid out is <1ml/kg/day * A CXR with <2cm from the lung apex or lateral edge of the lung to the inside family preference • Standard surgical wound care surface of the chest wall is likely <20%. Disclaimer: This guideline is designed for general use with most patients; each clinician should use his or her own independent judgment to meet the needs of each individual patient. This guideline is not a substitute for professional medical advice, diagnosis or treatment. M09245 Pneumothorax Guideline | Reviewer: Kurachek | Revised 4/17 | Page 1 HOSPITAL GUIDELINE PRIMARY SPONTANEOUS PNEUMOTHORAX (PSP) STANDARD PNEUMOTHORAX COMMUNICATION STANDARD COMMUNICATION FOLLOWING SURGICAL PLEURODESIS How successful is chest tube placement for a PSP? How successful is surgical pleurodesis at preventing recurrent 70% have resolution of the air leak in <3 days. pneumothorax? Surgical pleurodesis has a “cure” rate of 95%. How often does a recurrent pneumothorax occur on the same side? 40% have recurrence on the same side. Should a second PNX occur the risk is How uncomfortable to the patient is a surgical pleurodesis? higher than 60% for a third. The object of surgery is to disrupt the inner lining of the chest wall and lung How often will a recurrence happen on the opposite side? surface so that the two surfaces adhere to one another. This procedure is 10% of patients will experience a pneumothorax on the opposite side. painful and requires post-operative intravenous pain support. Can a pneumothorax be life-threatening? What are the complications of surgical pleurodesis? These events are relatively low risk. A mortality rate is quoted as <1%. The procedure is considered low risk but all procedures have unexpected risk. Low percentage complications include: unexpected bleeding, prolonged How successful is a surgical pleurodesis? air leak (>7 days); post-operative secretion retention and the requirement for 95% of patients are “cured” (no future recurrence) supplemental oxygen. How long after a chest tube placement for pneumothorax can the How long after surgery will my child be discharged? following activities be performed? Almost all children are discharged by 5 days depending on comfort. High aerobic and/or contact sports 4 weeks Commercial airline travel 4 weeks How long after surgical pleurodesis for pneumothorax can the following Travel to altitude (>8,000 feet) 4 weeks activities be performed? SCUBA diving Never High aerobic and/or contact sports 4–6 weeks Commercial airline travel 4–6 weeks Travel to altitude (>8,000 feet) 4–6 weeks SCUBA diving Never References: SHARED DECISION MAKING: 1. Baumann M. Management of PSP. Consensus statement ACCP. Chest 2001; 119:590-602. Primary spontaneous pneumothorax is a relatively low risk event in 2. MacDuff A. Management of PSP. British Thoracic Society guideline. Thorax.2010; 65 (Supp2):ii 18. 3. Robinson PD. Management of paediatric PSP: a multicentre retrospectivecase series. Arch Dis Child 2015; 100:918-923. most cases. Issues of recurrence, occurrence on the opposite side and 4. Soccorso G. Management of large PSP in children: proposed guideline.Pediatr Surg Int. 2015; 31:1139-1144. the decision to perform surgery hinge on the tolerance to risk. The 5. Lopez ME. Management of the pediatric PSP: is primary surgery the treatment of choice? Amer J of Surg. 2014; 208:571-576. thought of pneumothorax while on vacation may be paralyzing to one 6. Massongo M. Outpatient management of PSP: a prospective study.Eur Respir J. 2014; 43:582-590. 7. Dotson K. Pediatric PSP: CME review article. Ped Emerg Care. 2012; 28(7):715-720. family and presumed not likely by another. Family preference and 8. Seguier-Lipszyc E. Management of PSP in children. Clin Ped. 2011; 50(9):797-802. lifestyle issues will result in different conclusions by different families. 9. Laituri CA. The utility of CT in the management of PSP. J of Ped Surg. 2011;46:1523-1525. 10. Northfield TC. Oxygen for PSP. British Med J. 1971; 4:86-88. Disclaimer: This guideline is designed for general use with most patients; each clinician should use his or her own independent judgment to meet the needs of each individual patient. This guideline is not a substitute for professional medical advice, diagnosis or treatment. M09245 Pneumothorax Guideline | Reviewer: Kurachek | Revised 4/17 | Page 2.