Adrian,

Until relatively recently I too had a low threshold for formally draining all traumatic pneumothoraces.

There is little debate about the need for a formal drainage in patients who require ventilation, transfer to theatre or to another hospital, or who have tensioned at any time, or those with underlying lung disease.

The majority of patients we see in the ED, however, have small pneumothoraces with normal physiology, usually causing minimal (if any) symptoms in fit and healthy individuals. Many present 24 hours or more after injury.

I am now increasingly conservative with this latter groups of patients, and will aspirate these first line (if > 30 -50% and causing symptoms), and will consider over night admission to the CDU. Many of these patients can be successfully discharged home after a short period of observation, with a repeat check CXR prior to discharge and 2 weeks later.

The breach in the pulmonary visceral pleura usually seals rapidly which is why even simple aspiration will often be successful, especially if complete re-expansion can be achieved at the time of aspiration.

I have never been enthusiastic about an anterior approach for thoracocentesis (or formal drainage) because of the potential for disaster with close proximity of vital anatomical structures, even in the mid-clavicular line. I have always used a lateral approach (5^th intercostal space or above), and I do not rely on a catheter-over needle (14G venflon) to achieve adequate emergency pleural decompression in suspected tension pneumothorax.

Best wishes,

John Black

-----Original Message-----
From: Accident and Emergency Academic List [mailto:[log in to unmask]] On Behalf Of Adrian Fogarty
Sent: 30 March 2005 20:46
To: [log in to unmask]
Subject: Re: chest drains

That's certainly the way we used to do them 20-odd years ago! I think it went out of fashion as, let's face it, you're more likely to "prang" something in the mediastinum if you start putting big drains into the MCL. Conversely, I don't see anything wrong with doing needle thoracentesis in the axillary area! Cardiac surgeons place axillary drains postoperatively - in cases where they let the lungs down or where they approach endoscopically - and their mediastinal drains emanate from the sub-xiphisternal area. (I use the word "emanate" as they're inserted from inside out!)

With respect to aspiration, the BTS guidelines do strike me as odd. I've always thought that large pneumos, i.e. 50-90%, are highly unlikely to expand with aspiration simply because, by definition, the pulmonary leak must be quite large to allow such a big collapse, and is likely to be larger still as the lung expands and the parenchyma stretches particularly where the pneumo is recent (and where the leak will not have sealed). I always go straight for a drain - admittedly a slim Seldinger model these days - when faced with a large pneumothorax.

Regards

Adrian Fogarty

sri srinivas <[log in to unmask]> wrote:

recently i came across someone who had inserted a
chest drain size 28 in the ant mid clavicular line and
used suction for draining a spontaneous pnuemothorax
after aspirationx2 was unsucessful and still large.

is anterior chest midclavicular line a suitable
option rather than the traditional axillary approach.
do cardiothoracics use this approach?
would like some info before i approach concerned
person.

sri