Management of spontaneous pneumothorax

Comparison of Observation Alone Versus Interventional Procedures in Hemodynamically Stable Patients With Pneumothorax: A Systematic Review and Meta-Analysis

Several studies indicate that observation alone is sufficient for the management of stable pneumothorax. To compare clinical efficacy, tolerability, and safety outcomes for treating hemodynamically stable adult patients with pneumothorax, the present review compared observation alone versus interventional procedures. We searched PubMed and Google Scholar from inception until June 24, 2020, for randomized controlled trials (RCTs) comparing observational therapy with conventional therapy for the treatment of adult pneumothorax. The pediatric age group and patients with tension pneumothorax were not included. Four hundred and forty-six patients were enrolled in three RCTs. The failure rate (relative risk (RR) 4.30; 95% CI = 0.23-81.82, p = 0.33) and mortality (RR 1.01; 95% CI = 0.31-3.33, p = 0.98) of observation were comparable to those of the chest tube. Chest tube and observation both carried comparable risks of complications, including tension pneumothorax and empyema (RR 3.15; 95% CI = 0.67-1) and (RR 1.55; 95% CI = 0.21-11.56, p = 0.67), respectively. Between chest tubes and observation, there was no statistically significant difference in the duration of hospital stay. We conclude that observation is as safe and effective at treating adult patients with stable pneumothorax as a chest tube.

Conservative versus invasive treatment of primary spontaneous pneumothorax: a retrospective cohort study

Aim

The best management of primary spontaneous pneumothorax is unclear. Conservative treatment has been proposed, but no studies comparing conservative with invasive management have been carried out where pneumothorax size has been numerically quantified. This study aimed to evaluate the feasibility of conservative management for primary spontaneous pneumothoraces of any size.

Methods

Retrospective cohort study of adult patients with primary spontaneous pneumothorax treated at an Australian tertiary hospital from 2006-2011, carried out by case-note and chest radiograph review. Patient demographics, smoking status, and outcome data were collected. Pneumothorax size was calculated using the Collins method, based on the sum of interpleural distances.

Results

One hundred and twenty-seven episodes from 116 patients were identified. Males (86) comprised 75% of patients, and the median age at presentation was 37 years. Eighty-two percent of cases (106) were ever-smokers. Of the episodes in which pre-treatment radiographs were available, 53 were treated conservatively and 58 invasively with tube thoracostomy, and all were clinically stable. When cases were stratified by pneumothorax size, age, sex, ethnicity, and smoking status had no effect on outcome. Compared to invasive treatment, conservative management resulted in no complications, an equal recurrence rate, and a significantly shorter length of stay.

Conclusions

Our results suggest that it may be feasible to adopt a conservative approach as the first-line treatment of primary spontaneous pneumothorax in clinically stable patients. However, given the limitations of this study, a large randomised controlled trial is required to conclusively prove this assertion.

Three-step management of pneumothorax: time for a re-think on initial management

Pneumothorax is a common disease worldwide, but surprisingly, its initial management remains controversial. There are some published guidelines for the management of spontaneous pneumothorax. However, they differ in some respects, particularly in initial management. In published trials, the objective of treatment has not been clarified and it is not possible to compare the treatment strategies between different trials because of inappropriate evaluations of the air leak. Therefore, there is a need to outline the optimal management strategy for pneumothorax. In this report, we systematically review published randomized controlled trials of the different treatments of primary spontaneous pneumothorax, point out controversial issues and finally propose a three-step strategy for the management of pneumothorax. There are three important characteristics of pneumothorax: potentially lethal respiratory dysfunction; air leak, which is the obvious cause of the disease; frequent recurrence. These three characteristics correspond to the three steps. The central idea of the strategy is that the lung should not be expanded rapidly, unless absolutely necessary. The primary objective of both simple aspiration and chest drainage should be the recovery of acute respiratory dysfunction or the avoidance of respiratory dysfunction and subsequent complications. We believe that this management strategy is simple and clinically relevant and not dependent on the classification of pneumothorax.

Review of management of primary spontaneous pneumothorax: is the best evidence clearer 15 years on?

In 1993 Emergency Medicine Australasia (then Emergency Medicine [Fremantle]) published a therapeutic review on the management of spontaneous pneumothorax. That review found a lack of high-quality evidence on which to base management decisions and a variety of therapeutic options without clear superiority one over another. Now, almost 15 years later, the present paper aims to revisit the evidence base to see if management choices are clearer.