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Management of spontaneous pneumothorax
  1. S P HART
  1. Respiratory Medicine Unit
  2. Western General Hospital, Crewe Road
  3. Edinburgh EH4 2XU, UK
  4. whart{at}globalnet.co.uk

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    Editor,—Yeoh and colleagues were surprised that 80% of doctors opted to insert a chest drain for the initial management of a patient with a large pneumothorax,1 but the authors did not report which types of drain were used for pleural intubation. Narrow bore drains have been used successfully for the treatment of pneumothoraces for over a decade,2 3 and have the advantage over large intercostal drains in that they are free from the troublesome complication of subcutaneous emphysema that follows blunt dissection through the parietal pleura. Narrow bore chest drains that are quick, safe, and easy to insert by a Seldinger technique (for example, the Portex 12 FG drain kit) are now widely available and are very effective. In contrast (and contrary to the published guidelines), many practising respiratory and general physicians have found that pleural aspiration is a time consuming procedure that frequently fails.4 Typically, after laborious aspiration of two or more litres of air from the pleural cavity using a 50 ml syringe and then waiting for several hours for a further chest radiograph, it is found that the pneumothorax persists and the patient needs to have a chest drain inserted anyway. The availability of narrow bore chest drain kits means that in many centres “simple” aspiration will be largely abandoned in the treatment of moderate and large spontaneous pneumothoraces.

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    The authors respond:

    Dr Hart has raised interesting points. However, our study aimed to establish the current practice of Welsh physicians in the management of spontaneous pneumothorax, comparing it with the guidelines published by the British Thoracic Society (BTS),1-1 and highlighting some of the issues around variations from recommended practice. We hope to assist the BTS, which is set to review the evidence and revise the guidelines. The committee is debating the issues in the management, considering age of the patient, size and nature of the pneumothorax, and size of chest drain. Some of Dr Hart's points have already been discussed in our paper. We disagree with the suggestion that simple percutaneous aspiration should be abandoned. There is evidence that this treatment works in a significant proportion of patients. A 43% success rate for simple aspiration was reported by Seatonet al,1-2 and this has been exceeded in the recent randomised trials by Andrivetet al 1-3 and Harvey and Prescott1-4: 68% and 80% respectively. Besides, it is better tolerated by patients and is less painful.1-4 We recognise the lower rate of success with aspiration in cases of larger pneumothoraces.1-5 Despite that, it is still successful in a significant percentage and thus should be considered the initial treatment for the most.

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