Spontaneous recovery of ventilator-associated pneumothorax.

BACKGROUND The usual management of ventilator-associated pneumothorax (VPX) is tube thoracostomy. However, this recommendation is based on tradition rather than on solid evidence. Although it has been applied successfully to other types of pneumothoraces, observation has not been used in the management of VPX. OBJECTIVES In this study, we investigated whether observation is a valid treatment strategy for VPX. METHODS We retrospectively analyzed data of 471 patients with VPX (2003-2010) and found that 27 did not receive tube thoracostomy. Most of those patients (89%) had documented do-not-resuscitate orders and had refused tube thoracostomy. For comparison, 54 patients with tube thoracostomy, matched by age and do-not-resuscitate status, were chosen as controls. Among patients without tube thoracostomy, we compared attribute differences between those recovered and those not recovered. RESULTS Thirteen patients (48%) without tube thoracostomy experienced spontaneous recovery of their pneumothoraces. This rate of chest tube-free recovery was higher than that of patients with tube thoracostomy (48 vs. 17%; p = 0.003). The patients did not differ in in-hospital mortality rate, time to ventilator discontinuation or survival. By univariate logistic regression, spontaneous recovery was associated with VPX caused by needle puncture, lack of respiratory distress, large tidal volume and low oxygen requirement following pneumothorax, as well as by physician recommendation against intubation. CONCLUSION Observation under physician surveillance is an effective option of managing many VPXs, especially those caused by needle puncture, when patients are not in respiratory distress or when patients have acceptable tidal volumes and oxygen requirements following pneumothorax.