Spontaneous Recovery of Ventilator-Associated Pneumothorax

Abstract

Background: The usual management of ventilator-associated pneumothorax (VPX) is tube thoracostomy. However, this recommendation is based on tradition rather than on solid evidence. Although it has been applied successfully to other types of pneumothoraces, observation has not been used in the management of VPX. Objectives: In this study, we investigated whether observation is a valid treatment strategy for VPX. Methods: We retrospectively analyzed data of 471 patients with VPX (2003-2010) and found that 27 did not receive tube thoracostomy. Most of those patients (89%) had documented do-not-resuscitate orders and had refused tube thoracostomy. For comparison, 54 patients with tube thoracostomy, matched by age and do-not-resuscitate status, were chosen as controls. Among patients without tube thoracostomy, we compared attribute differences between those recovered and those not recovered. Results: Thirteen patients (48%) without tube thoracostomy experienced spontaneous recovery of their pneumothoraces. This rate of chest tube-free recovery was higher than that of patients with tube thoracostomy (48 vs. 17%; p = 0.003). The patients did not differ in in-hospital mortality rate, time to ventilator discontinuation or survival. By univariate logistic regression, spontaneous recovery was associated with VPX caused by needle puncture, lack of respiratory distress, large tidal volume and low oxygen requirement following pneumothorax, as well as by physician recommendation against intubation. Conclusion: Observation under physician surveillance is an effective option of managing many VPXs, especially those caused by needle puncture, when patients are not in respiratory distress or when patients have acceptable tidal volumes and oxygen requirements following pneumothorax.

Lung ultrasonography for the diagnosis of 11 patients with acute respiratory distress syndrome due to bird flu H7N9 infection

“…To maintain satisfactory oxygenation, a high PEEP value during ventilation was generally used, which possibly led to tension pneumothorax, especially when lung consolidation and pulmonary fibrosis developed. Once plural effusion or pneumothorax happened, the effective ventilation area decreased dramatically so that the hypoxemia was aggravated with a fatality [ 24 , 25 ]. Therefore, bedside lung ultrasonography could help us to discover pulmonary morphological changes in a timely manner and guide the puncture accurately, leading to a favorable prognosis.…”

Ventilator-Associated Pneumothorax: Drainage Is Not Always Necessary

“…This was based on a retrospective study in 74 patients that was published almost 4 decades ago [4], which reported signs of a tension component in 95% and a high mortality rate of 30% if drainage was delayed. However, in the observational study by Wu et al [5 ]in this issue of Respiration , this standard of care is questioned. The authors describe the outcome of a ventilator-associated pneumothorax without intervention in a group of 27 patients.…”

“…Particularly for such patients, a conservative approach may prevent prolonged hospitalization during active treatment of the pneumothorax. Confirmation in the form of an observational phase-II-type study would be appropriate to determine whether the findings of Wu et al [5] should lead to a change in current practice.…”