Spontaneous pneumothorax: pragmatic management and long-term outcome

Joint ERS/EACTS/ESTS clinical practice guidelines on adults with spontaneous pneumothorax

OBJECTIVES

The optimal management for spontaneous pneumothorax (SP) remains contentious, with various proposed approaches. This joint clinical practice guideline from the ERS, EACTS and ESTS societies provides evidence-based recommendations for the management of SP.

METHODS

This multidisciplinary Task Force addressed 12 key clinical questions on the management of pneumothorax, using ERS methodology for guideline development. Systematic searches were performed in MEDLINE and Embase. Evidence was synthesised by conducting meta-analyses, if possible, or narratively. Certainty of evidence was rated with GRADE (Grading, Recommendation, Assessment, Development and Evaluation). The Evidence to Decision framework was used to decide on the direction and strength of the recommendations.

RESULTS

The panel makes a conditional recommendation for conservative care of minimally symptomatic patients with primary spontaneous pneumothorax (PSP) who are clinically stable. We make a strong recommendation for needle aspiration over chest tube drain for initial PSP treatment. We make a conditional recommendation for ambulatory management for initial PSP treatment. We make a conditional recommendation for early surgical intervention for the initial treatment of PSP in patients who prioritise recurrence prevention. The panel makes a conditional recommendation for autologous blood patch in secondary SP patients with persistent air leak (PAL). The panel could not make recommendations for other interventions, including bronchial valves, suction, pleurodesis in addition to surgical resection or type of surgical pleurodesis.

CONCLUSIONS

With this international guideline, the ERS, EACTS and ESTS societies provide clinical practice recommendations for SP management. We highlight evidence gaps for the management of PAL and recurrence prevention, with research recommendations made.

SHAREABLE ABSTRACT

This update of an ERS Task Force statement from 2015 provides a concise comprehensive update of the literature base. 24 evidence-based recommendations were made for management of pneumothorax, balancing clinical priorities and patient views.https://bit.ly/3TKGp9e.

Joint ERS/EACTS/ESTS clinical practice guidelines on adults with spontaneous pneumothorax

BACKGROUND

The optimal management for spontaneous pneumothorax (SP) remains contentious, with various proposed approaches. This joint clinical practice guideline from the ERS, EACTS and ESTS societies provides evidence-based recommendations for the management of SP.

METHODS

This multidisciplinary Task Force addressed 12 key clinical questions on the management of pneumothorax, using ERS methodology for guideline development. Systematic searches were performed in MEDLINE and Embase. Evidence was synthesised by conducting meta-analyses, if possible, or narratively. Certainty of evidence was rated with GRADE (Grading of Recommendations, Assessment, Development and Evaluations). The Evidence to Decision framework was used to decide on the direction and strength of the recommendations.

RESULTS

The panel makes a conditional recommendation for conservative care of minimally symptomatic patients with primary spontaneous pneumothorax (PSP) who are clinically stable. We make a strong recommendation for needle aspiration over chest tube drain for initial PSP treatment. We make a conditional recommendation for ambulatory management for initial PSP treatment. We make a conditional recommendation for early surgical intervention for the initial treatment of PSP in patients who prioritise recurrence prevention. The panel makes a conditional recommendation for autologous blood patch in secondary SP patients with persistent air leak (PAL). The panel could not make recommendations for other interventions, including bronchial valves, suction, pleurodesis in addition to surgical resection or type of surgical pleurodesis.

CONCLUSIONS

With this international guideline, the ERS, EACTS and ESTS societies provide clinical practice recommendations for SP management. We highlight evidence gaps for the management of PAL and recurrence prevention, with research recommendations made.

Observation, Aspiration, or Tube Thoracostomy for Primary Spontaneous Pneumothorax: A Systematic Review, Meta-Analysis, and Cost-Utility Analysis

BACKGROUND

Primary spontaneous pneumothorax (PSP) has several commonly used management strategies: observation, aspiration, and chest tube placement. Economic modelling of pooled data comparing techniques has not been performed.

RESEARCH QUESTION

Based on studies from the past 20 years, which approach to management of PSP delivers the highest utility?

STUDY DESIGN AND METHODS

A systematic review of PSP management strategies (observation, aspiration, or chest tube placement) included in the Medline and EMBASE databases from January 1, 2000, through April 10, 2020, was conducted. Text screening, bias assessment, and data extraction were performed by two authors (G. E. and C. A. P.). Inclusion and exclusion criteria were defined a priori. The primary outcome was PSP resolution after the initial intervention. Secondary outcomes were PSP recurrence, length of stay, rate of surgical management, and complications. The meta-analysis compared treatment arms; dichotomous outcomes were reported as relative risk (RRs) and continuous outcomes were reported as mean differences. A cost-utility analysis within the Canadian health care system context with deterministic and probabilistic sensitivity analyses was performed.

RESULTS

Five thousand one hundred seventy-nine articles were identified; after screening, 22 articles were included. Most trials showed a high risk of bias, but randomized trials showed a lower risk. Compared with chest tube placement, observation (mean difference, 5.17; 95% CI, 3.75-6.59; P < .01; I2 = 62%) and aspiration (mean difference, 2.72; 95% CI, 2.39-3.04; P < .01; I2 = 0%) showed a shorter length of stay. Compared with observation, chest tube placement (RR, 0.81; 95% CI, 0.71-0.91; P < .01; I2 = 62%) and aspiration (RR, 0.73; 95% CI, 0.61-0.88; P < .01; I2 = 67%) showed higher resolution without additional intervention. Two-year recurrence rates did not differ between management strategies. Observation showed the best utility (0.82) and lowest cost; observation was the optimal strategy in 98.2% of Monte Carlo simulations.

INTERPRETATION

Observation is the dominant choice compared with aspiration and chest tube placement for PSP. It should be considered as the first-line therapy in appropriately selected patients.

Pediatric spontaneous pneumothorax

Spontaneous pneumothorax (SP) occurs when air enters the pleural space in the absence of a traumatic or iatrogenic etiology and is an uncommon phenomenon in the pediatric population. Although the typical presentation has been well described in the literature, much debate still surrounds the epidemiology, pathophysiology, diagnosis, and management of this condition in the pediatric population. To date, much of the emphasis in the pediatric literature has been on surgical options. Questions still remain regarding the true incidence of this disease in children, appropriate diagnostic imaging, and treatment recommendations for practitioners in the emergency department setting. This review of the evidence seeks to elaborate on current knowledge and clinical practice, as well as the applicability of adult recommendations to the pediatric population.

Implementation of a clinical pathway in primary spontaneous pneumothorax patients treated by wedge resection surgery

PURPOSE

This study was conducted to develop a clinical pathway for primary spontaneous pneumothorax (PSP) patients treated by wedge resection surgery. The authors also aimed to evaluate the effects of the implementation of the PSP clinical pathway on (1) complication occurrence rates, (2) self-efficacy with respect to PSP recurrence prevention, (3) patient-perceived quality of life, and (4) patient treatment satisfaction.

DESIGN

This study was conducted using a quasi-experimental, nonequivalent study design.

SAMPLE

The study subjects were 60 PSP patients admitted to the thoracic surgery departments at 2 university hospitals located in Seoul, South Korea.

METHODS

A retrospective medical record review was conducted to develop a PSP clinical pathway, and the developed clinical pathway was then applied to the treatment group (n = 30). Complication occurrence rates, self-efficacy with respect to PSP recurrence prevention, perceived quality of life, and patient treatment satisfaction were measured.

FINDINGS

The developed PSP clinical pathway is comprehensive and includes self-care and recurrence prevention education in addition to common protocols, such as medication and diagnostic tests. The pathway significantly improved self-efficacy with respect to preventing PSP recurrence, health-related quality of life, and patient treatment satisfaction, but did not reduce complication rates.

IMPLICATIONS

The present study offers a new comprehensive clinical pathway for PSP patients who have undergone wedge resection surgery. This study may be useful in the clinical nursing field by providing guiding standards for PSP-related education with respect to diet, exercise, self-supervision, complication, stress control, and recurrence prevention.

[Treatment specifics for spontaneous pneumothorax in flight personnel]

Spontaneous pneumothorax is one cause of aeronautical unfitness in flight personnel, because of the risk of recurrence in flight, making it an issue of flight safety. Specific treatment is required for fighter pilots, pilots flying single-pilot and pilots in professional training: surgical synthesis via video-thoracoscopy is obligatory from the first episode. Considering the exposure to an accumulation of aeronautical factors that are likely to encourage pneumothorax recurrence in flight, it is apical pleurectomy together with abrasion of the remaining pleura and resection of bullae/blebs that is required for fighter pilots to allow them to recover aeronautical fitness unrestrictedly. For all other categories of flight personnel, treatment is no different from that of the common patient. Knowledge of these treatment specifics is essential, to avoid unnecessary systematic surgical indication for all flight personnel, or jeopardise professional fitness in some of them due to inappropriate treatment.

Thoracoscopic bullectomy for primary spontaneous pneumothorax in pediatric patients

INTRODUCTION

Primary spontaneous pneumothorax is a condition that carries significant morbidities and mortalities if not managed properly. Thoracotomy with bullectomy has been the treatment of choice for persistent air leak or recurrence after initial chest drain insertion. With the advancement in minimal invasive surgery, the thoracoscopic approach can dramatically reduce the complications of open thoracotomy. We review our experience in managing spontaneous pneumothorax in children using thoracoscopy.

MATERIALS AND METHODS

The medical records of all patients who were discharged with the diagnosis of spontaneous pneumothorax from 1997 to 2007 were reviewed. The demographic data and management were noted. For those patients who underwent thoracoscopic surgery, the intra-operative findings, post-operative outcomes and complications were compared.

RESULTS

A total of 15 patients with spontaneous pneumothorax were identified. They all received chest drain insertion as the primary treatment modality. Nine patients, with mean age 16.1 +/- 0.9 years, failed the initial management and subsequently received thoracoscopic surgery with a mean interval of 7.6 +/- 2.5 days after initial chest drain insertion. Among these patients, bullae were found in seven patients (two patients had more than one bulla). The bullae were excised with mean operative time being 63.9 +/- 25.2 min. No conversion to thoracotomy was reported. All patients received paracetamol as pain control and there was no associated complication. No recurrence was found at follow-up till now.

CONCLUSION

This study confirms that the presence of bulla is commonly seen in patients with spontaneous pneumothorax who fail initial management. Thoracoscopic bullectomy, a safe and effective operation, should be offered to this group of patients.

Spontaneous pneumothorax in children: when is invasive treatment indicated?

A retrospective review of pneumothoraces in children presenting to a major tertiary children's hospital is described. A total of 35 cases in 31 patients of spontaneous pneumothorax were identified over a 10-year period. There was one case of bilateral pneumothorax and three cases of recurrent pneumothoraces. Twenty-four cases (69%) required intercostal tube catheter drainage for a mean of 4.9 days (range 2-10 days). Eleven cases, including two cases in CF patients, and three cases in patients with Marfan's Syndrome proceeded to a secondary surgical procedure after a continuing air leak was present for an average of 5.9 days (range 2-16 days). In follow-up studies on 11 cases, 5 (45%) were found to have apical abnormalities of the lung on CT scanning. Pneumothoraces were identified in six cases of patients with cystic fibrosis as well as four in patients with Marfan's Syndrome. This present study has suggested that unless intercostal catheter treatment resolves the air leak associated with a spontaneous pneumothorax within 5 days that surgical intervention is most likely to be required to achieve a full resolution.

Optimal Timing for Surgical Treatment to Prevent Recurrence of Spontaneous Pneumothorax

PURPOSE

Persistent air leakage and recurrence are the most common indications for the surgical treatment of spontaneous pneumothorax; however, the optimal timing for surgery is still unclear.

METHODS

The subjects of this study were 90 patients treated for either primary spontaneous pneumothorax (PSP; n = 58) or secondary spontaneous pneumothorax (SSP; n = 32). We compared the incidence of prolonged air leak, the rate of recurrence of pneumothorax, the time from the first episode of pneumothorax to recurrence, and the postoperative complications in the two groups. We also analyzed the recurrence rate after treatment with observation and tube drainage versus surgery.

RESULTS

Seventy-three patients were treated with tube thoracostomy or oxygen therapy for the first episode of pneumothorax. Surgery was performed in 32 patients; for the first episode of pneumothorax in 17 and for the second or third episode in 15. Postoperative complications developed in six (18.7%) patients and 24 of 73 patients who did not undergo thoracotomy suffered recurrence. The incidence of a second episode was 32.9% and the incidence of a third episode in the 18 patients who suffered recurrence after conservative treatment was 61.1%. None of the patients who underwent surgery suffered recurrence.

CONCLUSIONS

Tube thoracostomy is still the treatment of choice for first-time spontaneous pneumothorax. However, because the incidence of a third episode of pneumothorax after conservative treatment is high, surgical treatment should always be considered for patients with recurrence. In short, surgical intervention is safe and effective and minimizes the chance of recurrence of both PSP and SSP.

Factors related to recurrence of spontaneous pneumothorax

OBJECTIVES

The purpose of this retrospective study was to identify factors associated with recurrent spontaneous pneumothorax (SP) in southern China, and to compare the therapeutic effectiveness of different procedures.

METHODS

A total of 182 consecutive patients (89.0% male; mean age, 38.9 years), admitted with their first episode of pneumothorax, were reviewed retrospectively. Follow up was available in 138 patients (75.8%), including 68 treated by chemical pleurodesis and 70 by chest tube drainage alone. The cumulative recurrence rates with different therapeutic procedures and different chemical sclerosing agents were compared, and the factors that influenced the recurrence rate were analysed using Cox's proportional hazard model.

RESULTS

The most common pre-existing lung disease responsible for pneumothorax was COPD (69.7%), followed by tuberculosis (16.5%). Recurrence was significantly more common in taller patients, patients with lower weight, and patients with secondary spontaneous pneumothorax. The cumulative recurrence rates in the pleurodesis therapy group after 6 months, 1 and 3 years were 13, 16 and 27%, respectively, whereas in the chest tube drainage group the recurrence rates were 26, 33 and 50%, respectively (P < 0.05). There was no significant difference in the recurrence rate for those receiving tetracycline compared with those who received gentamicin.

CONCLUSIONS

Spontaneous pneumothorax patients who are taller, weigh less or have secondary spontaneous pneumothorax are more likely to have recurrences. The risk of recurrence is reduced in patients who undergo chemical pleurodesis. Since there was no significant difference between intrapleural tetracycline and gentamicin, gentamicin should be considered as a potential chemical sclerosing agent.