Re: insertion of the drain

In general call a thoracic surgeon when the situation for the drain is anything other than straightforward, e.g.,

·       Difficult site, e.g. loculated effusion, adhesions.

·       When another form of management may be more appropriate

·       When the patient has had problems with drains previously

·       When there are medico-legal implications to the insertion of the drain.

Re: management of the pneumothorax

Most pneumothoraces do not require surgical intervention but respond to re-insertion of a chest drain of sufficient size placed in the apex. Referral for thoracic surgical opinion is recommended when:

·       Complication of a drain,

·       Drain not working,

·       Persistent bubbling for 4 days - it is recommended that contact be made with thoracic surgery if there is persistent bubbling at four days to pre-empt the usual delay in obtaining a bed. (In Belfast, Thoracic surgery will then agree to make a bed available in the Royal Victoria Hospital within a working week.)

·       Failure of the lung to re-expand after appropriate placement of a drain.

·       Need for a second drain/Advice on re-location of a chest drain -

In the above situations please page the Thoracic registrar on call (Ward 4a - 02890 632016 will give you the appropriate pager number). Please do not call the Thoracic Office in these circumstances.

Re: management of recurrent primary pneumothoraces

In general thoracic surgeons will operate electively in the following circumstances:

·       First ipsilateral recurrence of pneumothorax (i.e. second pneumothorax on same side)

·       Patients at high risk should a recurrence occur i.e. pilots. frequent fliers or scuba divers

·       Any patient who has suffered a tension pneumothorax.

In these circumstances please refer to thoracic outpatients in the usual way. It may be more appropriate to refer for urgent operation rather than inserting another chest drain ar attempting aspiration.

Re: management of secondary pneumothoraces.

These are a complicated issue as these patients have both respiratory and surgical problems. Much of the morbidity related to treating secondary pneumothoraces is due to these unfit patients being immobilised for lengthy periods. These patients need to be referred early to either the Belfast City Hospital or the Royal Victoria Hospital to allow combined management by the respiratory physicians and thoracic surgeons. Most will NOT receive surgery but will receive no-surgical pleurodesis as appropriate.