Management of pneumothorax has traditionally been tube thoracostomy and -20 cmH20 suction. Our objective was to determine if underwater seal (WS) in iatrogenic and spontaneous pneumothoraces was safe and efficacious.
An IRB-approved, prospective, randomized trial enrolled patients with iatrogenic or spontaneous pneumothorax treated with small caliber tube thoracostomy (9fr). Large air leaks (>4/7) were treated with immediate operative intervention and excluded. For the rest, initial management was brief (1–2 hours) -20 cmH20 suction followed by chest radiography and randomization into one of three groups: -20 cmH20 suction, -10 cmH20 suction or WS. Tubes were discontinued at 48h if there was no pneumothorax and no air leak. Air leaks and recurrent pneumothoraces persisting for 5 days underwent pleurodesis.
Thirty patients were enrolled from April of 2001 to September 2003, with none requiring immediate surgery. Seven were randomized to -20 cmH20, 12 to -10 cmH20 and 11 to WS. One patient had a persistent pneumothorax on WS and crossed over to -10 cmH20. The majority (N=18, 62%) of chest tubes were removed 48h after placement: 4/7 (57%) of -20cmH20, 9/13 (69%) of -10 cmH20, and 5/10 (50%) of WS (p=NS). Seven patients (23%) required pleurodesis: 2/7 (29%) in -20 cmH20, 3/13 (23%) in -10 cmH20, and 2/10 (20%) in WS (p=NS).
The use of early WS is safe for the treatment of iatrogenic and spontaneous pneumothorax. It achieved similar frequencies of early chest tube removal and avoidance of surgery compared with traditional management strategy.
Treatment of iatrogenic and spontaneous pneumothoraces may effectively incorporate the use of small-caliber catheters and underwater seal.
J.M. Lyons, None.