No abstract

Primary spontaneous pneumothorax (PSP) occurs in apparently healthy young people with an incidence of 12.5 cases per 100 000 per year [1]. Attempts to develop standardised care guidelines for this condition have been severely hampered by a lack of high-quality clinical research into this condition. The American College of Chest Physicians (CHEST) concluded in 2001 that “insufficient data exist…to develop an evidence-based document” and so produced a consensus statement based on expert opinion [2]. Similarly, the British Thoracic Society (BTS) 2010 guidelines are based predominantly on nonanalytical studies and expert opinion [3]. In both documents, the size of the presenting PSP is used to determine initial treatment. A “small” PSP without respiratory compromise is thought not to require intervention, while a “large” PSP has typically been treated either by aspiration or intrapleural drainage. Implicit in these definitions is the belief that large pneumothoraces will not respond well to conservative management. Remarkably, no consensus regarding the definition of PSP severity exists, with CHEST and the BTS each using different arbitrary measurements of the presentation chest radiograph. When these measurements were compared directly to one another, they showed poor correlation [4]. This lack of a clinically useful radiological biomarker for pneumothoraces requiring intervention hinders the development of evidence-based care of this condition. We wished to determine whether the BTS definition of large pneumothorax (>2 cm at the hilum) or CHEST definition (>3 cm from apex to cupola) better predicts the requirement for intercostal chest drain (ICD) insertion.

Having established an ambulatory service for patients with suspected and proven PE, we reviewed our outcomes. All patients referred from June 2010 to May 2012 were analysed. Of 971 patients referred, 905 underwent complete assessment (66 admitted as ineligible). 754 (77.7%) patients were discharged and required no follow-up. 96 (10.6%) patients had PE confirmed of whom 70 (72.9%) were managed as outpatients. 14 (1.6%) patients have died since attending the clinic; no death was related to PE. This audit shows that ambulatory investigation and management of selected low risk patients with suspected PE is safe and reduces hospital admissions.

IntroductionThe optimal management of pneumothorax remains undefined. There is a growing consensus that patients with spontaneous pneumothorax can be considered for ambulatory management with the use of a one-way valve. Despite this, there is little data on the outcomes of outpatient management of secondary spontaneous pneumothorax (SSP).MethodsAt our institution, selected patients with primary and secondary spontaneous pneumothorax who meet the predefined local criteria are managed on an ambulatory pathway. We prospectively evaluated our practice over a 3-year period and explore outcomes of patients with SSP using primary spontaneous pneumothorax (PSP) as a comparator group.Results163 consecutive patients presenting to our hospital between September 2014 and July 2017 were evaluated using a predefined protocol. 111 (49 SSP and 62 PSP) were deemed suitable for outpatient management. Resolution on day 5 was similar between the two groups (65% in the SSP vs 79% in the PSP group; p=0.108). The mean drainage time was 5.84 days in SSP compared with 5.69 days in PSP, representing a difference of 0.15 days (95% CI −2.47 to 2.16; p=0.897). Complications such as infection and drain blockage/falling-out were scarce, with comparable pain and satisfaction scores across both groups. There were no deaths during this period. An estimated £86 796 ($113 920) was saved over the study period, equating to £1118.80 ($1550) per patient.DiscussionThis study suggests that outpatient management of selected patients with SSP may be effective, safe and cost-saving.

Cryptogenic Organising Pneumonia (COP) is a relatively rare condition and can be difficult to differentiate from Community acquired pneumonia (CAP). We report two cases which demonstrate the importance of considering this differential diagnosis in patients with spontaneous pneumothorax who have raised inflammatory markers or lung infiltrates. Our report highlights the value of serum procalcitonin as a biomarker in differentiating between community acquired pneumonia and cryptogenic organising pneumonia especially in the context of a high serum C-reactive protein. Furthermore, the cases show early diagnosis and prompt treatment with corticosteroids may impact the clinical outcome.