Spontaneous Pneumothorax – Chest Tube or Watchful Waiting?
April 1, 2020
Written by Vivian Lei
Spoon Feed
Conservative management of moderate-to-large size spontaneous pneumothorax was noninferior to interventional management, with lower risk of complications and recurrence.
Why does this matter?
Traditionally, patients presenting with a large spontaneous pneumothorax are treated with chest tube placement and hospital admission. This study flips the current treatment dogma and suggests that a conservative approach of observation is noninferior to interventional therapy. Furthermore, patients may benefit from decreased morbidity due to lower rates of adverse events, surgical intervention, and recurrence of pneumothorax.
Primary Spontaneous Pneumothorax (PSP) trial
This was a multicenter, randomized, noninferiority trial conducted at 39 sites in Australia and New Zealand. In total, 316 patients aged 14-50 with a moderate-to-large primary spontaneous pneumothorax were randomized to either interventional management or conservative management. The intervention group had a small-bore chest tube placed in the ED. If the pneumothorax had resolved after 1 hour of water seal and 4 hours of clamping, the chest tube was removed and the patient was discharged. If the pneumothorax did not resolve or there was recurrence, the patient was admitted. In the conservative management group, patients were observed for at least 4 hours and discharged if they did not require supplemental oxygen, were walking comfortably, and did not require further interventions based on clinician discretion (i.e. physiologic instability, enlarging pneumothorax on repeat chest x-ray).
Of the patients managed conservatively, 84.6% were ultimately spared from any invasive intervention. At an 8 week follow-up, 98.5% of patients in the intervention group and 94.4% of the conservative management group had resolution of pneumothorax. This met the researchers’ goal of non-inferiority, although they admitted it was statistically “fragile” due to issues accounting for missing data at the 8 week follow-up. Ultimately, patients managed conservatively did quite well with fewer adverse events, shorter hospitalizations and days off work, less radiographic imaging, lower rates of surgery, and lower rates of recurrences in the first 12 months (8.8% versus 16.8% in the intervention group).
Another Spoonful
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EM Lit of Note also has a thoughtful summary.
Source
Conservative versus Interventional Treatment for Spontaneous Pneumothorax. N Engl J Med. 2020 Jan 30;382(5):405-415. doi: 10.1056/NEJMoa1910775.
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