[The EXPRED study: where are we?]

Simple Aspiration versus Drainage for Complete Pneumothorax: A Randomized Noninferiority Trial

Rationale: Management of first episodes of primary spontaneous pneumothorax remains the subject of debate. Objectives: To determine whether first-line simple aspiration is noninferior to first-line chest tube drainage for lung expansion in patients with complete primary spontaneous pneumothorax. Methods: We conducted a prospective, open-label, randomized noninferiority trial. Adults aged 18-50 years with complete primary spontaneous pneumothorax (total separation of the lung from the chest wall), recruited at 31 French hospitals from 2009 to 2015, received simple aspiration (n = 200) or chest tube drainage (n = 202) as first-line treatment. The primary outcome was pulmonary expansion 24 hours after the procedure. Secondary outcomes were tolerance of treatment, occurrence of adverse events, and recurrence of pneumothorax within 1 year. Substantial discordance in the numerical inputs used for trial planning and the actual trial rates of the primary outcome resulted in a reevaluation of the trial analysis plan. Measurement and Main Results: Treatment failure occurred in 29% in the aspiration group and 18% in the chest tube drainage group (difference in failure rate, 0.113; 95% confidence interval [CI], 0.026-0.200). The aspiration group experienced less pain overall (mean difference, -1.4; 95% CI, -1.89, -0.91), less pain limiting breathing (frequency difference, -0.18; 95% CI, -0.27, -0.09), and less kinking of the device (frequency difference, -0.05; 95% CI, -0.09, -0.01). Recurrence of pneumothorax was 20% in this group versus 27% in the drainage group (frequency difference, -0.07; 95% CI, -0.16, +0.02). Conclusions: First-line management of complete primary spontaneous pneumothorax with simple aspiration had a higher failure rate than chest tube drainage but was better tolerated with fewer adverse events. Clinical trial registered with www.clinicaltrials.gov (NCT01008228).

Le drainage thoracique aux urgences dans la prise en charge d’un épanchement pleural non traumatique

Le drainage thoracique est un geste classique en médecine d’urgence. En dehors du traumatisé thoracique, les indications de drainage thoracique aux urgences sont essentiellement le pneumothorax spontané primitif ou secondaire et les épanchements pleuraux liquidiens en cas d’épanchement parapneumonique compliqué. La technique doit être connue des médecins urgentistes qui sont confrontés à la prise en charge initiale de ces patients. Le matériel de drainage ou « drainage pleural catheter », selon la terminologie proposée par Baumann, regroupe l’ensemble des matériels de thoracocentèse laissés en place au décours du geste. Il existe une multiplicité de matériel à disposition des cliniciens qui permettent de réaliser un drainage thoracique et le choix dépend de l’indication. Les drains classiques avec mandrin sont utilisés dans le cas des épanchements liquidiens. Les drains percutanés, moins invasifs, sont préférentiellement choisis pour un épanchement gazeux. Les complications associées à ces dispositifs sont différentes selon le type du drain. Les recommandations préconisent le recours à des drains de petits calibres et vont dans le sens de méthodes de moins en moins invasives, notamment dans le cas des pneumothorax. Les modalités de transport des patients drainés sont également importantes à connaître pour la prise en charge des patients avec un drain thoracique. La possibilité d’un traitement ambulatoire en cas de pneumothorax spontanés avec un mini-drain relié à une valve de Heimlich® (Vigon, Écouen, France) ou le recours à un drain tunnélisé en cas de pleurésie récidivante constituent des options intéressantes en médecine d’urgence.

Techniques d’exsufflation d’un pneumothorax

Les pneumothorax rencontrés aux urgences peuvent être d’origine spontanée ou traumatique. L’exsufflation est une méthode thérapeutique simple du pneumothorax spontané primitif. Cette technique consiste à réaliser une aspiration par l’intermédiaire d’un cathéter, sans que le matériel soit laissé en place. Elle permet une prise en charge ambulatoire du patient et répond à des enjeux de qualité des soins (efficacité, simplicité, sécurité) et d’économie de la santé (diminution de la durée et du taux d’hospitalisation). L’exsufflation peut être réalisée via différents dispositifs tout simples d’utilisation, par voie antérieure ou axillaire. L’exsufflation à l’aiguille avec des cathéters de perfusion intraveineux est peu recommandée devant le risque d’échec lié à une longueur de cathéter inadaptée à la morphologie du patient. Les usages de drains de faible calibre avec la méthode de Seldinger ou de kits dédiés de thoracentèse sont à privilégier. Les complications sont moindres comparées à la pose d’un drain thoracique. Il s’agit le plus souvent d’obstruction ou de déplacement du cathéter. L’exsufflation est également un geste de sauvetage à réaliser en urgence en cas de pneumothorax suffocant. La bonne maîtrise de l’une de ces techniques est donc indispensable dans le cadre de la formation et de la pratique en médecine d’urgence.

How spontaneous pneumothorax is managed in emergency departments: a French multicentre descriptive study

Background

Management of spontaneous pneumothorax (SP) is still subject to debate. Although encouraging results of recent studies about outpatient management with chest drains fitted with a one-way valve, no data exist concerning application of this strategy in real life conditions. We assessed how SP are managed in Emergency departments (EDs), in particular the role of outpatient management, the types of interventions and the specialty of the physicians who perform these interventions.

Methods

From June 2009 to May 2013, all cases of spontaneous primary (PSP) and spontaneous secondary pneumothorax (SSP) from EDs of 14 hospitals in France were retrospectively included. First line treatment (observation, aspiration, thoracic drainage or surgery), type of management (admitted, discharged to home directly from the ED, outpatient management) and the specialty of the physicians were collected from the medical files of the ED.

Results

Among 1868 SP included, an outpatient management strategy was chosen in 179 PSP (10%) and 38 SSP (2%), mostly when no intervention was performed. Only 25 PSP (1%) were treated by aspiration and discharged to home after ED admission. Observation was the chosen strategy for 985 patients (53%). In 883 patients with an intervention (47%), it was performed by emergency physicians in 71% of cases and thoracic drainage was the most frequent choice (670 patients, 76%).

Conclusions

Our study showed the low level of implementation of outpatient management for PS in France. Despite encouraging results of studies concerning outpatient management, chest tube drainage and hospitalization remain preponderant in the treatment of SP.

Electronic supplementary material

The online version of this article (10.1186/s12873-018-0213-2) contains supplementary material, which is available to authorized users.

Simple aspiration versus intercostal tube drainage for primary spontaneous pneumothorax in adults

BACKGROUND

For management of pneumothorax that occurs without underlying lung disease, also referred to as primary spontaneous pneumothorax, simple aspiration is technically easier to perform than intercostal tube drainage. In this systematic review, we seek to compare the clinical efficacy and safety of simple aspiration versus intercostal tube drainage for management of primary spontaneous pneumothorax. This review was first published in 2007 and was updated in 2017.

OBJECTIVES

To compare the clinical efficacy and safety of simple aspiration versus intercostal tube drainage for management of primary spontaneous pneumothorax.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 1) in the Cochrane Library; MEDLINE (1966 to January 2017); and Embase (1980 to January 2017). We searched the World Health Organization (WHO) International Clinical Trials Registry for ongoing trials (January 2017). We checked the reference lists of included trials and contacted trial authors. We imposed no language restrictions.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) of adults 18 years of age and older with primary spontaneous pneumothorax that compared simple aspiration versus intercostal tube drainage.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, assessed trial quality, and extracted data. We combined studies using the random-effects model.

MAIN RESULTS

Of 2332 publications obtained through the search strategy, seven studies met the inclusion criteria; one study was ongoing and six studies of 435 participants were eligible for inclusion in the updated review. Data show a significant difference in immediate success rates of procedures favouring tube drainage over simple aspiration for management of primary spontaneous pneumothorax (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.69 to 0.89; 435 participants, 6 studies; moderate-quality evidence). Duration of hospitalization however was significantly less for patients treated by simple aspiration (mean difference (MD) -1.66, 95% CI -2.28 to -1.04; 387 participants, 5 studies; moderate-quality evidence). A narrative synthesis of evidence revealed that simple aspiration led to fewer adverse events (245 participants, 3 studies; low-quality evidence), but data suggest no differences between groups in terms of one-year success rate (RR 1.07, 95% CI 0.96 to 1.18; 318 participants, 4 studies; moderate-quality evidence), hospitalization rate (RR 0.60, 95% CI 0.25 to 1.47; 245 participants, 3 studies; very low-quality evidence), and patient satisfaction (median between-group difference of 0.5 on a scale from 1 to 10; 48 participants, 1 study; low-quality evidence). No studies provided data on cost-effectiveness.

AUTHORS' CONCLUSIONS

Available trials showed low to moderate-quality evidence that intercostal tube drainage produced higher rates of immediate success, while simple aspiration resulted in a shorter duration of hospitalization. Although adverse events were reported more commonly for patients treated with tube drainage, the low quality of the evidence warrants caution in interpreting these findings. Similarly, although this review observed no differences between groups when early failure rate, one-year success rate, or hospital admission rate was evaluated, this too needs to be put into the perspective of the quality of evidence, specifically, for evidence of very low and low quality for hospitalization rate and patient satisfaction, respectively. Future adequately powered research is needed to strengthen the evidence presented in this review.

[Treatment of the first episode of spontaneous pneumothorax]

INTRODUCTION

The management of a first episode of spontaneous pneumothorax is controversial and the best technique to be used as an initial intervention, aspiration or intercostal drainage, is still debated.

PATIENTS AND METHODS

We present a retrospective case series during two and a half consecutive years describing the immediate management of spontaneous pneumothoraces, comparing aspiration versus thoracic drainage.

RESULTS

One hundred and thirty-three clinical files from patients with spontaneous pneumothoraces were analyzed (17 primary and 116 secondary). The pneumothoraces were of varying size and different etiologies. Patients were initially treated with simple aspiration in 68 cases, with an immediate success rate of 37.5%, intercostal drainage in 49 cases, and by rest alone in 16 cases.

CONCLUSION

In case of secondary pneumothorax, aspiration appeared to offer advantages as an initial strategy over intercostal drainage in terms of hospital stay (11 versus 22 days), and with significant effectiveness (37.5%).