Treatment of Pneumothorax: "I Think Analogue Systems Will Disappear, Because They're Much Less Helpful."

Kris Mooren is a Pulmonologist at the Spaarne Gasthuisin Haarlem (Netherlands) and co-author of the research paper “Digital versus analogue chest drainage system in patients with primary spontaneous pneumothorax: a randomized controlled trial”.1 During an interview Dr Mooren shared some additional insights and thoughts after the publication of the research.

How did you get the idea for the trial?

"I am interested in the treatment of spontaneous pneumothorax because it's interesting to really know what happens within the pleural cavity."

I am interested in the treatment of spontaneous pneumothorax because it's interesting to really know what happens within the pleural cavity, how much air leak there is.  Do we use the information that digital systems are able to give us? Surgeons did a lot of research with digital systems and pulmonologists did not do any research at all, even though we work with digital systems every day.

When a patient presents with pneumothorax, usually the physician doesn’t immediately connect a chest tube, but performs manual aspiration only. If there is a persistent air leak, then people get a chest tube. Our hypothesis, which we formed after the Dutch Pneumothorax Study, is that it's much more effective to connect these people immediately to Thopaz. If it is an ‘uncomplicated’ pneumothorax, you will see a high airflow, which declines quickly to zero. Then you know you can probably take the chest tube out, although based on our trial, we do advise to perform a chest X-ray to make sure the lung has approximated again. On the other hand, in some patients you will see a non-declining air leak, which tells you that you will probably need a surgeon. So we've learned a lot from this study. If I would set it up again, I would do it differently.

What would you do differently?

I would make better use of the information on air leak patterns that Thopaz is able to give. We compared two devices, Thopaz and the analog device, but we treated the patients the same way. Three times a day, we looked at the system and we said, "bubbles, no bubbles" or, "air leak, no air leak." But we didn't use the intelligent information that Thopaz is able to give.

“The patients who have a high but quickly declining air leak, they have an uncomplicated pneumothorax and don't need a lengthy hospital stay.”

It would be interesting to use Thopaz+ for stratifying which patients need surgery and which don’t. The patients who have a high but quickly declining air leak, they have an uncomplicated pneumothorax and don't need a lengthy hospital stay. They maybe don't even need to stay in the hospital: home treatment is a very interesting option that is possible with your device. You could send patients home with the device because the patient can tell the nurse or the doctor who calls: “I see that there is still 40 ml/min., or there is zero”. “Okay, if it's zero come to the hospital and we'll take out your chest tube.” So in short, we didn't really use all the useful information that Thopaz is able to give.

What kind of obstacles did you run into during this study?

The main obstacle was the number of patients.

We never thought we would have a problem with recruitment because it's a common condition, but it was a little bit difficult to randomize patients. I mean, it was easy when you know how to, but you know what it's like, people are admitted out of hours. So in the middle of the night, they were given a chest tube and nobody tried to randomize between the digital and the analog system.

Also, it was interesting to know that nurses and doctors actually didn't want patients to be on the analogue system because once you work with the digital, it's like going back in time. So during rounds, they would say: "Why does this patient have the analogue system? It doesn't give all the information I need". So that was an obstacle as well.

There was a group of patients who stayed in the hospital for a very long time. So their length of hospital stay had a huge effect on the statistics. When we just looked at the patients who recovered really quickly, so typically the young, healthy people who don't have any emphysema or damaged lungs otherwise, they did really well with Thopaz.

So our main recommendation was Thopaz is a very interesting device actually to use as a substitute for a manual aspiration which is done mostly in the UK.

Manual aspiration as the first choice for therapy, are you questioning that with this publication?

Yes, we think manual expiration is not practical because you've punctured the thorax anyway and if you use a very small catheter, so a very, very small tube, you might just as well connect it to the Thopaz. It's easier than pumping out the air by yourself because it takes a lot of time and you don't know exactly what you're doing. Thopaz is going to tell you how much air leak there is and how quickly it declines.

"In practice in our hospital we immediately use Thopaz and we see what's happening because some people have this very specific pattern."

In practice in our hospital, this is what we do: once the patient presents itself and there is a need for drainage, we immediately use Thopaz and we see what's happening, because some people have this very specific pattern. You connect the tube, they start coughing, you have a lot of air leak and then it quickly declines and they're practically good to go. So sometimes they can leave the hospital the very next day.

Kris, I have talked to some other colleagues of yours and they're saying on their patients when the air leak is not decreasing within 48 hours, it's mostly a sign that it will take much longer. They recommend you make an intervention early after 48 hours...

In practice now, we wait 72 hours but the interesting question, that would be something for another research project: if people have a non-declining air leak, maybe you should consult the surgeon earlier because it's possible that those patients will profit from earlier intervention. We know that the chance of having a recurring pneumothorax is about 25%. So that is quite large already and if these people have a long air leak, it is possible - but that is a hypothesis of course - that the lung parenchyma is more fragile, it leaks for longer, so it doesn't heal as quickly.

From your perspective, what do you think the future has in store for digital chest drainage systems?

"I think analog systems will disappear because they're much less helpful."

Firstly, I think analogue systems will disappear because they're much less helpful. Secondly, that digital drainage systems are probably going to be used at home more than is happening now. Thirdly, I think it might be a good alternative for manual aspiration, to immediately insert the digital system. And my fourth and final point, I think it might be possible to stratify between patients who are going to have a prolonged air leak and need surgery and people who will heal quickly. So that's what I think the future holds and there'll probably be more, but that's for you, not for me.

Thopaz+ takes chest drainage therapy to a new level of care

  • Thopaz+ reduces chest tube duration and length of stay (in hospital).
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  • Clinical staff find Thopaz+ more convenient and easier to use than conventional chest drainage systems.
  • Visit our FAQ for more information about safe chest drain management.

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References

1 Ruigrok D, Kunst PWA, Blacha MMJ et al. Digital versus analogue chest drainage system in patients with primary spontaneous pneumothorax: a randomized controlled trial. BMC Pulmonary Medicine (2020) 20:136. https://link.springer.com/content/pdf/10.1186/s12890-020-1173-3.pd