We are very excited this month to bring you another installment of the ALiEM-Annals of EM Global Journal Club. The highlighted article is Voison et al. on the “Ambulatory Management of Large Spontaneous Pneumothorax With Pigtail Catheters.” We hope you will participate in an online discussion based on the clinical vignette and questions below from now until Nov 17, 2014. Respond by commenting below or tweeting using the hashtag #ALiEMJC. In a few months, a summary of this journal club will be published in Annals of EM.

On Fri, Nov 14, 2014, we hosted a live Google Hangout with Dr. Stéphane Jouneau, the senior author of the Annals of EM publication who resides in France.

Google Hangout with Dr. Jouneau: Nov 14, 2014

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• 00:00 Dr. Michelle Lin (UC San Francisco) makes introductions and outlines the planned discussion.
• 01:20 Dr. Seth Trueger (Univ of Chicago) summarizes the highlighted paper on spontaneous pneumothorax
• 03:40 Dr. Heather Murray (Queen’s University) and Dr. Stéphane Jouneau (Univ of Rennes 1) discuss about aspiration technique as an option.
• 06:50 Dr. Trueger summarizes blog comments for Dr. Jouneau to reflect on.
• 14:15 Dr. Jouneau shares things/ stories that didn’t appear on his paper.
• 15:55 Dr. Jouneau advocates for the use of checklists by the providers to ensure procedural quality and systems consistency.
• 17:00 Dr. Murray and Dr. Jouneau discuss training of emergency physicians at his institution on this seldinger technique for pigtail catheters, kinking complications, and post-procedural chest x-rays.
• 19:05 Dr. Trueger and Dr. Jouneau expand on the issue of getting vs not getting a post-procedural chest x-ray.
• 20:43 Dr. Murray and Dr. Jouneau discuss about complications and the safety of pigtail catheters used in the outpatient setting. In the his study, two patients had kinking of the catheter which prevented lung re-expansion.
• 23:48 The panelists wrap up with some key take-home points.

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Journal Club Paper

Voisin F, Sohier L, Rochas Y, Kerjouan M, Ricordel C, Belleguic C, Desrues B, Jouneau S. Ambulatory management of large spontaneous pneumothorax with pigtail catheters. Ann Emerg Med. 2014 Sep;64(3):222-8. PMID: 24439715.

Abstract

STUDY OBJECTIVE: There is no consensus about the management of large spontaneous pneumothoraces. Guidelines recommend either needle aspiration or chest tube drainage and most patients are hospitalized. We assess the efficiency of ambulatory management of large spontaneous pneumothoraces with pigtail catheters.

METHODS: From February 2007 to January 2011, all primary and secondary large spontaneous pneumothoraces from Lorient’s hospital (France) were managed with pigtail catheters with a 1-way valve. The patients were discharged immediately and then evaluated every 2 days according to a specific algorithm.

RESULTS: Of the 132 consecutive patients (110 primary, 22 secondary), 103 were exclusively managed as outpatients, with full resolution of the pneumothorax by day 2 or 4, which represents an ambulatory success rate of 78%. Mean time (SD) of drainage was 3.4 days (1.8). Seven patients were initially hospitalized but quickly discharged and had full resolution by day 2 or 4, leading to a total success rate of 83%. The use of analgesics was low. The 1-year recurrence rate was 26%. If successful, this outpatient management is potentially cost saving, with a mean cost of $926, assuming up to 2 outpatient visits and 1 chest radiograph, compared with $4,276 if a chest tube was placed and the patient was admitted to the hospital for 4 days.

CONCLUSION: Ambulatory management with pigtail catheters with 1-way valves could be a reasonable first-line of treatment for large spontaneous pneumothoraces. Compared with that of other studies, our protocol does not require hospitalization and is cost saving.

Journal Jam podcast

Dr. Anton Helman and Dr. Teresa Chan provide their insightful summary take-home points in their podcast of the Google Hangout discussion and crowdsourced comments.

Open Access Online Content on Topic

Actual implementation documents mentioned in Google Hangout (in French)

Dr. Jouneau shares his site’s implementation and checklist documents below. Although the four files are in French, through Google Translate you can get a sense of what they say.

1. Checklist for providers before patient discharge (docx, 22 kb)
2. Consultation fax form to the pulmonologists for follow-up (ppt, 224 kb)
3. Discharge instruction form for the patients on the care of the Hiemlich value and catheter (doc, 46 kb)
4. Discharge instruction form for the patients teaching about pneumothoraces (32 kb)

Featured Questions

Four questions are featured here to spark discussion and reflection about the highlighted paper. For more of a deep-dive into the methodologies, check out the Journal Club questions published in Annals of EM [free PDF] . If you have additional questions, feel free to pose them!

• Q1: How do you (and/or your centre) manage patients with new or recurrent large spontaneous pneumothorax (defined as >2-3 cm from lung apex). Catheter aspiration? Inpatient 8-12F chest tube? Pigtail catheter? Other?
• Q2: If you were designing the randomized controlled trial (RCT) of ambulatory pigtail catheter insertion for spontaneous pneumothorax (PTX), what would your comparator be? What outcome measures would you like to see? What measure of difference in this outcome(s) would convince you to change your practice?
• Q3: All the pigtail catheters were placed by respirologists in this study (there were 5 physicians who performed all the insertions). Are there complications that might be more likely to occur in the hands of less experienced operators?
• Q4: Assuming that the ambulatory pigtail catheters are shown to be equivalent or superior to traditional care in a future RCT, do you think this protocol would be feasible in your setting? Are there barriers to implementation at your hospital?

Please participate in the journal club by answering either on the ALiEM blog comments below or by tweeting us using the hashtag #ALiEMJC. Please denote the question you are responding to by starting your reply with Q1, Q2, Q3, or Q4.

Disclaimer: We reserve the right to use any and all tweets to #ALiEMJC and comments below in a commentary piece for an Annals of EM publication as curated conclusion piece for this global journal club. Your comments will be attributed, and we thank you in advance for your contributions.

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