American Journal of Emergency Medicine 32 (2014) 488.e3-488.e8

Contents lists available at ScienceDirect

American Journal of Emergency Medicine

journal homepage: locate/ ajem

Case Report

Point-of-care ultrasound for assisting in Needle aspiration of Spontaneous pneumothorax in the pediatric ED: a case series?

Abstract

There is controversy regarding needle aspiration for Primary spontaneous pneumothorax (PSP), with contradictory recommenda- tions between the American College of Chest Physicians consensus statement (2001), which suggests that needle aspiration has little place in the management of PSP, and the British Thoracic Society guidelines (2010), which recommend that needle aspiration be attempted first for all cases of PSP where drainage is deemed necessary. Studies have shown that there is no significant difference between needle aspiration and tube thoracostomy with regard to safety, rates of immediate success, and early failure and has the advantages of decreasing pain and reducing rates of hospital admission and duration of hospital stay compared with tube thoracostomy. Point-of-care ultrasound can facilitate needle aspiration by decreasing the risk of complications and detect pneumothorax resolution during or re-expansion after the procedure. This is a case series where the sonographic finding of the “lung point” on point-of-care US was used to facilitate needle aspiration to monitor pneumothorax resolution during or re-expansion after the procedure. We report 3 cases of PSP in adolescents presenting to the pediatric emergency department (ED), where needle aspiration was safely performed by using US to track the sonographic finding of the lung point. This technique allows the determination of pneumothorax resolution or re-expansion in real time. Point-of-care US may assist in the evaluation and management of spontaneous pneumothorax in the pediatric ED. Ultrasound-assisted needle aspiration may be a safe and less painful option for pediatric ED patients with PSP.

There is controversy regarding the initial management of primary spontaneous pneumothorax (PSP), with contradictory recommenda- tions between the American College of Chest Physicians consensus statement (2001), which suggests that needle aspiration has little place in the management of PSP, and the British Thoracic Society guidelines (2010), which recommend that needle aspiration be attempted first for all cases of PSP where drainage is deemed necessary [1,2].

In recent years, the use of point-of-care ultrasound (US) in the emergency department (ED) setting has expanded because of its portability, absence of ionizing radiation, and its ability to be performed rapidly and serially [3]. Two of these applications include diagnosing pneumothoraces and assisting in thoracentesis. Both of these uses of point-of-care US can be applied to assisting in the treatment of pneumothorax.

? Disclosure: No sources of support to disclose. No financial relationships to disclose.

No conflicts of interest to disclose.

In treating PSP, there has been no significant difference between needle aspiration and tube thoracostomy with regard to safety, rates of immediate success, and early failure [4-6].

Furthermore, needle aspiration has the advantages of decreased pain, reduced rates of hospital admission, and duration of hospital stay compared with tube thoracostomy [6-9]. Despite these benefits, needle aspiration for PSP in the United States is not routinely used compared with European countries [10]. As outlined in the British Thoracic Society guidelines and also advocated by the Cochrane Collaboration, needle aspiration should be the First-line treatment for all PSP requiring intervention [2,4]. Point-of-care US can facilitate needle aspiration by decreasing the risk of complications [11]. Moreover, point-of-care US can be used to detect pneumothorax resolution during the needle aspiration procedure and can be repeated serially to monitor for its recurrence [12]. We report 3 cases of PSP in adolescents presenting to a pediatric ED, where US was performed to monitor resolution of pneumothorax during needle aspiration by tracking the sonographic finding of the lung point (Fig. 1) [13,14].

A 17-year-old Adolescent boy with no significant medical history presented to the pediatric ED with left pleuritic chest pain after basketball practice 2 hours before presentation. He denied any trauma or similar episodes in the past, and his review of systems was otherwise negative. In the ED, his vital signs were temperature of 35.4?C, blood pressure of 142/90 mm Hg, pulse rate of 64 beats per minute, respiratory rate of 16 breaths per minute, and O₂ saturation of 100% on room air.

His examination was unremarkable except for left lower anterior chest wall pain on inspiration and when lying in the Left lateral decubitus position. Point-of-care US diagnosed a pneumothorax that was confirmed by chest x-ray, which showed a pneumothorax measuring 4.1 cm from apex (parietal pleura) to cupola (visceral pleura) (Fig. 2A and Video 1 http://youtu.be/8gF5sQVU3s8). An US- assisted needle aspiration was performed with the patient in the supine position by identifying and tracking the lung point to the needle aspiration site as 500 mL of air was aspirated. Repeat chest x-ray following needle aspiration showed reduction of pneumothorax size (Fig. 2B). The patient was admitted for observation overnight. His hospital course was uncomplicated. A follow-up chest x-ray demon- strated re-expansion of the left lung with a minimal left apical pneumothorax, and the patient was discharged home the next morning. The patient has not had recurrence of PSP as of the writing of this report.

An 18-year-old Mandarin-speaking man with no significant medical history presented to the pediatric ED with a cough for 1 week. He denied any shortness of breath, Chest tightness, chest pain, trauma, or similar episodes in the past, and the remainder of his review of systems was negative. In the ED, his vital signs were

0735-6757/$ - see front matter (C) 2014

Fig. 1. A theoretical explanation of the lung point. Left: At expiration, the pneumothorax has a defined volume on computed tomography. A probe placed at a point slightly superior to the lung level will display a pneumothorax pattern. Right: At inspiration, the lung volume should slightly increase, therefore increasing the surface of the lung in contact with the wall. The probe remaining at the same location will thus display a fleeing pattern of lung, that is, Lung sliding and/or “B lines.” With permission from Intensive Care Med 2000;26(10):1434-40.

temperature of 35.3?C, blood pressure of 98/55 mm Hg, pulse rate of 60 beats per minute, respiratory rate of 16 breaths per minute, and O₂ saturation of 99% on room air. His examination was notable for decreased breath sounds in the right upper lung field. A point-of-care US diagnosed a pneumothorax that was confirmed by chest x-ray, which showed a pneumothorax measuring 3 cm from apex to cupola (Fig. 3A and Video 2 http://youtu.be/Zz17c0RUzzY). An US-assisted needle aspiration was performed with the patient in the supine position by identifying and tracking the lung point to the needle aspiration site as 200 mL of air was aspirated. Repeat chest x-ray following needle aspiration showed reduction of pneumothorax size (Fig. 3B). The patient was admitted to the cardiothoracic surgery service for overnight observation. His hospital course was uncompli- cated. A follow-up chest x-ray the next morning revealed a diminished size of right apical pneumothorax, and the patient was discharged home.

On a follow-up cardiothoracic surgery clinic visit 3 days after discharge, a repeat chest x-ray showed near resolution of the right apical pneumothorax. However, a routine follow-up chest x-ray 1

week later showed a significant enlargement of the right-sided pneumothorax. He was referred to the pediatric ED for evaluation. His vital signs were within normal limits, and he was asymptomatic. On examination, he had significantly decreased breath sounds on the right side of the chest. Despite the fact that the patient was successfully treated with needle aspiration, the reaccumulation of air suggested that he needed a more definitive treatment. Therefore, a right-sided video-assisted thoracoscopic surgery (VATS) was per- formed. It demonstrated blebs in the right upper and middle lobes, which were resected. A right apical parietal pleurectomy and mechanical pleurodesis were also done, and tube thoracostomy was performed. The patient’s hospital course was unremarkable; his chest tube was replaced with a Pigtail catheter on hospital day 6 and subsequently removed as output ceased. The patient was discharged home on hospital day 10 in stable condition. The patient has not had recurrence of spontaneous pneumothorax as of the writing of this report.

A 19-year-old man with a history of recurrent PSP presented with moderate right-sided sharp chest pain for 3 days. He described the

4.1 cm

A Before Needle Aspiration

2.1 cm

B After Needle Aspiration

Fig. 2. Case 1 chest X-rays.

1.9 cm

3 cm

A Before Needle Aspiration

B After Needle Aspiration

Fig. 3. Case 2 chest x-rays.

pain as similar to the 2 previous PSP he experienced 1 year (2012) and 2 years (2011) prior. The remaining review of systems was negative. In the pediatric ED, the patient’s vital signs were temperature of 36.5?C, blood pressure of 122/68 mm Hg, heart rate of 102 beats per minute, respiratory rate of 18 breaths per minute, and O₂ saturation of 98% on room air. His examination was remarkable for decreased breath sounds in the right upper and middle lung fields. A point-of- care US performed revealed a pneumothorax with the lung point

identified at the posterior axillary line (Video 3 http://youtu.be/ kZonNXlUXJA). A chest x-ray showed a large right-sided pneumo- thorax measuring 6.9 cm from apex to cupola (Fig. 4A). An US-assisted needle aspiration was performed with the patient in the supine position by identifying and tracking the lung point to the needle aspiration site as 1500 mL of air was aspirated. On repeat chest x-ray following aspiration, there was a reduction in the size of the pneumothorax (Fig. 4B). The patient was admitted for observation

3.9 cm

6.9 cm

A Before Needle Aspiration

B After Needle Aspiration

Fig. 4. Case 3 chest x-rays.

Fig. 5. Equipment for needle aspiration.

overnight. His hospital course was complicated by re-expansion of the pneumothorax, and a pigtail catheter was placed. However, the pneumothorax increased in size despite the pigtail catheter being attached to suction. He therefore underwent a right-sided VATS blebectomy and pleurodesis. The pneumothorax resolved, and the patient has not experienced recurrence of spontaneous pneumotho- rax as of the writing of this report.

To describe the US-assisted needle aspiration procedure, general lung US terminology will be reviewed here [17]. The “pleural line” is visualized on US as a hyperechoic line seen between 2 ribs and at the level of the inferior rib border. “Lung sliding” is the regular rhythmic movement of the parietal and visceral pleura that is synchronized with respiration (Video 4 http://youtu.be/ZVR-H4p4GOw). The absence of this movement suggests a pneumothorax at that location (Video 1). “Lung point” refers to the physical margin between the pneumothorax and normal lung with apposed parietal and visceral pleura (Fig. 1 and Video 5 http://youtu.be/mIlURa0GwXQ). The presence of lung point is pathognomonic (100% specific) for the

diagnosis of pneumothorax and maps its location to the patient’s chest wall. Lung point in the anterior chest wall (from sternum to anterior axillary line) correlates with small pneumothoraces, whereas a lung point found posterior to the posterior axillary line correlates with large pneumothoraces [13].

The technique and equipment for needle aspiration of pneumo- thorax have been reviewed and presented on video by Pasquier et al (http://www.nejm.org/doi/full/10.1056/NEJMvcm1111468 and Fig. 5) [15,16]. Ultrasound-assisted needle aspiration was performed using a high-frequency (10-7.5 MHz) linear transducer to identify the lung point in the sagittal orientation with the probe marker aimed cephalad while the patient was in the supine position (Figs. 6 and 7A-C). The distance of the skin to the pleural line at the needle aspiration site was measured by US and used to estimate the depth of needle insertion into the pleural space. This will allow the operator to limit the depth of needle insertion to avoid puncturing the lung during aspiration of the pneumothorax [17]. In addition, Color Doppler imaging can be used to identify and avoid vascular structures such as the intercostal, internal mammary, and subclavian vessels [18]. During aspiration, the US probe was moved along the chest wall medially to track the location of the lung point until the lung point was adjacent to the needle aspiration site.

The epidemiology and pathophysiology of PSP have been reviewed by Dotson and Johnson [10] previously. The use of point-of-care US to diagnose pneumothorax and to facilitate needle aspiration in PSP in the pediatric ED has not been described in the medical literature [10]. Ultrasound has superior sensitivity compared with chest x-ray (89% vs 52%), and both have equally high specificity (98% vs 99%) for diagnosing pneumothorax [19,20]. In addition, US has been shown to reduce complications, and it decreases costs associated with thor- acentesis [11,21]. All 3 cases reported here demonstrate the safety and utility of using US assistance for needle aspiration.

In the first case, point-of-care US showed a PSP that was safely treated with US-assisted needle aspiration and no complication or recurrence followed. This has served as definitive treatment for this patient and avoided the discomfort and additional expense of tube thoracostomy.

In the second case, point-of-care US showed a PSP that was also safely treated with US-assisted needle aspiration. His lack of

Ultrasound Probe Footprint

X3 X

X2

X1

X - Needle Aspiration Site

Fig. 6. Lung points travels from X1 to X2 to X3 towards X as air aspirated. (with patient in supine position).

Puncturing Chest Wall B: Aspiration Using Syringe with 3 - way Stopcock

C: Aspiration of Pneumothorax using Syringe with 3 way Stopcock and Linear Transducer monitoring Lung Point Progression

A:

Fig. 7. An ultrasound probe was used to identify the lung point in the sagittal orientation and was moved along the chest wall medially during pneumothorax aspiration until the lung point was adjacent to the needle aspiration site shown in panel 7C. With permission from Acad Emerg Med 2010;17(4):e25-6.2010.

symptoms and the near resolution of the PSP on follow-up examination 3 days later suggest that the needle aspiration was initially successful. That his PSP recurred more than 1 week later suggests that one can safely be discharged home following needle aspiration as long as close follow-up is arranged.

In the third case, point-of-care US showed a large PSP that initially responded to needle aspiration. However, after the procedure, the pneumothorax was found to be re-expanding as the lung point moved away from the needle aspiration site on serial US examinations (Fig. 6). The patient was admitted, and a pigtail catheter was inserted. However, he continued to have persistence of the pneumothorax and required VATS blebectomy and pleurodesis. This demonstrates the usefulness of US in monitoring the re-expansion or recurrence of pneumothorax. By following the lung point toward or away from the needle aspiration site, one can determine the success or failure of the procedure.

Although needle aspiration was not the definitive treatment in two of the cases, US helped facilitate the safety of these procedures and led to short-term resolution of PSP. There is a rising expectation that more emergency physicians will be familiar with the needle aspiration technique and offer it to patients as a treatment option for PSP given that is less painful and less invasive than pigtail catheter placement or tube thoracostomy [15]. Ultrasound assistance may help physicians

facile in US feel more comfortable incorporating this technique in the United States and may increase the safety of needle aspiration by monitoring pneumothorax resolution or re-expansion and the detection of potential postprocedure hemothorax [18].

Point-of-care US may assist in the evaluation and management of spontaneous pneumothorax in the pediatric ED. Ultrasound-assisted needle aspiration may be a safe and less painful option for pediatric ED patients with PSP. However, further research is needed to quantify the additional benefit of US assistance such as higher procedural success and decreased complications as compared with a chest x-ray and landmark technique alone.

Carrie Ng, MD

Department of Pediatrics Bellevue Hospital Center/NYU School of Medicine

New York, NY 10016, USA

E-mail address: [email protected]

James W. Tsung, MD, MPH

Departments of Emergency Medicine and Pediatrics

Mount Sinai School of Medicine

New York, NY, USA

http://dx.doi.org/10.1016/j.ajem.2013.11.011

References

1. Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi Consensus Statement. Chest 2001;119:590-602.
2. MacDuff A, Arnold A, Harvey J. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax 2010;65(Suppl 2):ii18-31.
3. American College of Emergency Physicians Policy Statement: emergency ultrasound guidelines. Ann Emerg Med 2009;53(4):550-70.
4. Wakai A, O’Sullivan R, McCabe G. Simple aspiration versus intercostal tube drainage for primary spontaneous pneumothorax in adults (review). The Cochrane Collaboration 2011;1:1-8.
5. Noppen M, Alexander P, Driesen P, et al. Manual aspiration versus chest tube drainage in first episodes of primary spontaneous pneumothorax: a multicenter, prospective, randomized pilot study. Am J Respir Crit Care Med 2002;165:1240-4.
6. Ho KK, Ong ME, Koh MS, et al. A randomized controlled trial comparing minichest tube and needle aspiration in outpatient management of primary spontaneous pneumothorax. Am J Emerg Med 2011;29:1152-7.
7. Devanand A, Koh MS, Ong TH, et al. Simple aspiration versus chest-tube insertion in the management of primary spontaneous pneumothorax: a systematic review. Respir Med 2004;98:579-90.
8. Chan SS. The role of simple aspiration in the management of primary spontaneous pneumothorax. The Journal of Emergency Medicine 2008;34(2):131-8.
9. Robinson PD, Cooper P, Ranganathan SC. Evidence-based management of paediatric primaryspontaneouspneumothorax.Paediatric Respiratory Reviews 2009;11:110-7.
10. Dotson K, Johnson LH. Pediatric spontaneous pneumothorax. Pediatric Emergency Care 2012;28(7):715-20.
11. Mercaldi CJ, Lanes SF. Ultrasound guidance decreases complications and improves the cost of care among patients undergoing thoracentesis and paracentesis. Chest 2013;143(2):532-8.
12. Galbois A, Ait-OUfella H, Baudel JL, et al. Pleural ultrasound compared with chest radiographic detection of pneumothorax resolution after drainage. Chest 2010;138(3):648-55.
13. Lichtenstein D, Meziere G, Biderman P, et al. The “lung point”: an ultrasound sign specific to pneumothorax. Intensive Care Med 2000;26(10):1434-40.
14. Volpicelli G, Elbarbary M, Blaivas M, et al. International evidence-based recommendation for point-of-care Lung ultrasound. Intensive Care Med 2012;38(4):577-91.
15. Pasquier M, Hugli O, Carron PN. Needle aspiration of primary spontaneous pneumothorax. N Eng J Med 2013;368:e24.
16. Brandler ES, Fontenette D, Stone MB. Needle aspiration of spontaneous pneumothorax. Acad Emerg Med 2010;17(4):e25-6.
17. Butler KL, Best IM, Weaver WL, et al. Pulmonary artery injury and cardiac tamponade after needle decompression of a suspected Tension pneumothorax. J Trauma 2003;54:610-1.
18. Rawlins R, Brown KM, Carr CS, et al. Life threatening haemorrhage after anterior needle aspiration of pneumothoraces. A role for lateral needle aspiration in emergency decompression of spontaneous pneumothorax. Emerg Med J 2003;20: 383-4.
19. Ding W, Shen Y, Yan J, et al. Diagnosis of pneumothorax by radiography and ultrasonography: a meta-analysis. Chest 2011;140(4):859-66.
20. Raja AS, Jacobus CH. How accurate is ultrasonography for excluding pneumotho- rax? Ann Emerg Med 2013;61(2):207-8.
21. Gordon CE, Feller-Kopman D, Balk EM, et al. Pneumothorax following thoracent- esis. Arch Intern Med 2010;170(4):332-9.