Deviation from published guidelines in the management of primary spontaneous pneumothorax in Australia

Update on the management of first episode primary spontaneous pneumothorax in an Australian hospital network

International guidelines and recent research favour a less interventional approach to primary spontaneous pneumothorax (PSP). A retrospective clinical audit of 68 first-episode PSP was undertaken at a major tertiary teaching hospital network in Melbourne, Australia, found that most patients presenting with a moderate to large pneumothorax received initial intercostal catheter insertion (56%), though many (81%) would have met criteria for consideration of conservative management. The results suggest continued deviation from clinical guidelines in the management of PSP.

Implementation of evidence on management of pleural diseases: insights from a territory-wide survey of clinicians in Hong Kong

BACKGROUND

Major advances in management of common pleural diseases have taken place in the past decade. However, pleural diseases are often managed by physicians of diverse training background and research on implementation of new knowledge is scanty. We aim to evaluate the practice pattern in pleural medicine among physicians in Hong Kong, for identification of possible gaps for clinical service improvement.

METHODS

The Hong Kong Thoracic Society undertook a cross-sectional questionnaire survey in 2019, targeting clinicians of various subspecialties in internal medicine and levels of experience (basic and higher trainees, specialists) from twelve regional hospitals of diverse service scopes throughout Hong Kong. Respondents were selected by non-probability quota sampling. The questionnaire tool consisted of 46 questions covering diagnostic and therapeutic aspects of common pleural diseases. The responses were anonymous, and analysed independently using SPSS statistics software.

RESULTS

The survey collected 129 responses, 47(36%) were from clinicians specialized in respiratory medicine. Majority of the respondents (98%) managed pleural diseases, including performing pleural procedures in their practice. Fifty-five percent of all the respondents had not received any formal training in transthoracic ultrasonography. A significant proportion of clinicians were unaware of pleuroscopy for investigation of exudative pleural effusion, indwelling pleural catheter for recurrent malignant pleural effusion, and combined intra-pleural Alteplase plus DNase for treatment of pleural infection (30%, 15% and 70% of non-respiratory clinicians respectively). Significant heterogeneity was found in the management of pleural infection, malignant pleural effusion and pneumothorax among respiratory versus non-respiratory clinicians. Contributing factors to the observed heterogeneity included lack of awareness or training, limited accessibility of drugs, devices, or dedicated service support.

CONCLUSION

Significant heterogeneity in management of pleural diseases was observed among medical clinicians in Hong Kong. Continuous medical education and training provision for both specialists and non-specialists has to be strengthened to enhance the implementation of advances, improve quality and equity of healthcare provision in pleural medicine.

Comparison of efficiency and safety of conservative versus interventional management for primary spontaneous pneumothorax: A meta-analysis

BACKGROUND

There is growing opinion that primary spontaneous pneumothorax (PSP) patients without hemodynamic compromise could be safely and successfully managed with observation alone. The aims of this meta-analysis were to estimate the safety and effectiveness of conservative treatment compared with that of interventional management as the initial treatment option for patients with PSP.

METHODS

The PubMed, Embase and Cochrane library databases were systematically searched for randomized controlled trials (RCTs) and cohort studies (prospective or retrospective) until April 25, 2020, that compared conservative treatment and interventional treatment as the initial treatment for patients with PSP. The primary outcomes were success rates and recurrence rates. The secondary outcome was complication rates. Data extraction and quality assessment from eligible studies were independently conducted by two reviewers.

RESULTS

8 trials with a total of 1342 patients were identified. The success rates of conservative management were similar with interventional treatment, with a risk ratio 1.05 (95% confidence interval 0.94 to 1.17, I2 = 69.1%). There was no significant difference of recurrence rates between these two type managements. (RR, 1.43, 95% confidence interval 0.45 to 4.55, I2 = 86.7%). Complication rates were lower in conservative treatment group (13 of 215 [6.05%]) than in interventional treatment group (57 of 212, [26.89%]), although the difference did not reach statistical significance (RR, 0.15, 95% CI, 0.02 to 1.13, I2 = 56.7%).

CONCLUSIONS

Results of the meta-analysis suggest that conservative treatment offers a safe and effective alternative as compared with interventional management as the initial treatment approach for patients with PSP. However, more randomized clinical trials are need to provide more strong evidence to confirm our results.

Measurement of intrapleural pressure in patients with spontaneous pneumothorax: a pilot study

Background

The initial management of pneumothorax remains controversial, and we speculated that this might be because there is no method available for evaluation of air leak during initial management. We have developed a system for measurement of intrapleural pressure in pneumothorax to address air leak without the need for chest drainage. The aim of this clinical study was to confirm the ability of this measurement system and to determine the clinical impact of management of air leak.

Methods

Patients in whom need aspiration was indicated for spontaneous pneumothorax were enrolled in the study. The intrapleural pressure was measured during stable breathing and data recorded when patients were coughing were excluded.

Results

Eleven patients were enrolled in the study between December 2016 to July 2017. The patterns in change of intrapleural pressure varied widely depending on the state of the pneumothorax. The mean intrapleural pressure values on end-inspiration and end-expiration in patients with persistent air leak was significantly lower than those in patients without persistent air leak (p = 0.020). The number of negative mean pressure recordings in end-inspiration and end-expiration was significantly lower in patients with persistent air leak than in those without persistent air leak (p = 0.0060).

Conclusions

In this study, we demonstrated that intrapleural pressure could be successfully measured and visualized in patients with pneumothorax. Whether or not the pressure value is a predictor of persistent air leak needs to be confirmed in the future.

A project to assess the quality of the published guidelines for managing primary spontaneous pneumothorax from the Italian Society of Thoracic Surgeons

OBJECTIVES

A project to assess the existing literature and the quality of past guidelines on the management of primary spontaneous pneumothorax was developed by the Italian Society of Thoracic Surgeons, with particular focus on the assessment of the methods used to produce such recommendations.

METHODS

The different items and domains within each guideline were assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument and scored on a 7-point scale.

RESULTS

Five guidelines matched the inclusion criteria and were assessed. A multinational collaboration produced 2 of 5 guidelines. The observers recommended (with modifications) only 2 guidelines. Clarity of presentation, scope and purpose (objectives and health questions target the population) received the best score, whereas the applicability of the guideline received the lowest score. International development positively influenced the scope and purpose of the guidelines. Moreover, improved scores were achieved when the stakeholders were fully involved and had editorial independence.

CONCLUSIONS

As assessed by the AGREE II criteria, the quality of the various guidelines was extremely inconsistent. Guidelines with higher AGREE II scores were those developed with the participation of European scientific societies.

New insights and improved strategies for the management of primary spontaneous pneumothorax

The pathophysiology and management of primary spontaneous pneumothorax (PSP) are a subject of debate. Despite advances in the understanding of its etiopathogenesis and improvements in its management, implementation in clinical practice is suboptimal. In this manuscript, we review the recent literature with a focus on PSP pathophysiology and management. Blebs and emphysema-like changes (ELC) are thought to contribute to the pathophysiology of PSP but cannot explain all cases. Recent studies emphasize the role of a diffuse porosity of the visceral pleura. Others found a relationship between smoking, occurrence of a PSP and bronchiolitis, which could be the initial pathological process leading to ELC development. Recent or ongoing studies challenge the need to systematically remove air from the pleural cavity of stable patients, introducing conservative management as a valuable therapeutic option. Evidence is growing in favour of needle aspiration instead of chest tube insertion, when air evacuation is needed. In addition, ambulatory management is considered as a successful approach in meta-analyses and is under exploration in a large randomized study. Because of a high recurrence rate of PSP, the benefit of performing a pleurodesis at first occurrence is under evaluation with interesting but not generalizable results. Better identification of 'at risk patients' is needed to improve the investigation strategy. Finally, recent publications confirm the efficacy, security and cost-effectiveness of graded talc poudrage pleurodesis to prevent PSP recurrence. In conclusion, PSP pathophysiology and management are still under investigation. The results of recently published and ongoing studies should be more widely implemented in clinical practice.

Chest tube drainage versus needle aspiration for primary spontaneous pneumothorax: which is better?

Background

Needle aspiration and chest tube drainages are two main treatments for primary spontaneous pneumothorax (PSP). However, the application of needle aspiration or chest tube drainages has not reached a consensus. The aim of this study is to compare the needle aspiration with chest tube drainages in patients suffering with PSP and therefore help offer suggestions for clinical practice.

Methods

We searched literatures from PubMed, OVID and Web of Science from their inception to June 30, 2017. Continuous and dichotomous outcomes were expressed by weight mean difference (WMD) and risk ratio (RR) respectively, and each with 95% confidence intervals (CIs). We used the fixed effect or random effect model to perform quantitative synthesis.

Results

A total of 6 RCTs recruiting 458 participants were included in our analysis. On the basis of the six studies, our results indicated that compared with chest tube drainage applying needle aspiration shortened the hospital stay (WMD: ‒1.67 days; 95% CI: ‒2.25 to 1.08; P<0.001) and decreased hospitalization rate (RR: 0.40; 95% CI: 0.22-0.75; P=0.004). However, there was no difference regarding immediate success rate (RR: 1.01; 95% CI: 0.70-1.46; P=0.96) and one-year recurrence rate (RR: 0.89; 95% CI: 0.58-1.38; P=0.61).

Conclusions

In the light of this present research, it is necessary to apply needle aspiration into treating PSP to reduce hospitalization rate and shorten hospital stay. However, the two treatments have no significant difference with respect to immediate success rate, one-year recurrence rate, one-week success rate, three-month recurrence rate or complication rate.

Randomised comparison of needle aspiration and chest tube drainage in spontaneous pneumothorax

Guidelines on spontaneous pneumothorax are contradictory as to intervention between needle aspiration (NA) and chest tube drainage (CTD). Studies show poor adherence to guidelines.

Three Norwegian hospitals included patients with primary (PSP) and secondary (SSP) spontaneous pneumothorax. Patients underwent NA or CTD as the primary intervention. The main outcome was duration of hospital stay. Secondary outcomes were immediate- and 1-week success rates and complications.

127 patients were included, including 48 patients with SSP. 65 patients underwent NA, 63 patients CTD. Median (interquartile range) hospital stay was significantly shorter for NA: 2.4 days (1.2–4.7 days), compared with CTD: 4.6 days (2.3–7.8 days) (p<0.001). The corresponding figures for the SSP subgroup were 2.54 days (1.17–7.79 days) compared with 5.53 days (3.65–9.21 days) (p=0.049) for NA and CTD, respectively. Immediate success rates were 69% for NA compared with 32% for CTD (p<0.001). The positive effect of NA remained significant in sub-analyses for SSP. There was no significant difference in 1-week success rates. Complications occurred only during the CTD-treatment.

Our study shows shorter hospital stay and higher immediate success rates for NA compared with CTD. Subgroup analyses also show clear benefits for NA for both PSP and SSP.

ERS task force statement: diagnosis and treatment of primary spontaneous pneumothorax

Primary spontaneous pneumothorax (PSP) affects young healthy people with a significant recurrence rate. Recent advances in treatment have been variably implemented in clinical practice. This statement reviews the latest developments and concepts to improve clinical management and stimulate further research.The European Respiratory Society's Scientific Committee established a multidisciplinary team of pulmonologists and surgeons to produce a comprehensive review of available scientific evidence.Smoking remains the main risk factor of PSP. Routine smoking cessation is advised. More prospective data are required to better define the PSP population and incidence of recurrence. In first episodes of PSP, treatment approach is driven by symptoms rather than PSP size. The role of bullae rupture as the cause of air leakage remains unclear, implying that any treatment of PSP recurrence includes pleurodesis. Talc poudrage pleurodesis by thoracoscopy is safe, provided calibrated talc is available. Video-assisted thoracic surgery is preferred to thoracotomy as a surgical approach.In first episodes of PSP, aspiration is required only in symptomatic patients. After a persistent or recurrent PSP, definitive treatment including pleurodesis is undertaken. Future randomised controlled trials comparing different strategies are required.

Spontaneous pneumothorax; a multicentre retrospective analysis of emergency treatment, complications and outcomes

BACKGROUND

Spontaneous pneumothorax can be managed initially by observation, aspiration or chest drain insertion.

AIMS

To determine the clinical features of spontaneous pneumothorax in patients presenting to the emergency department (ED), interventions, outcomes and potential risk factors for poor outcomes after treatment.

METHODS

Retrospective chart review from ED of three major referral and two general hospitals in Australia of presentations with primary spontaneous pneumothorax (PSP) or secondary spontaneous pneumothorax (SSP). Main outcomes were prolonged air leak (>5 days) and pneumothorax recurrence within 1 year.

RESULTS

We identified 225 people with PSP and 98 with SSP. There were no clinical tension pneumothoraces with hypotension. Hypoxaemia (haemoglobin oxygen saturation measured by pulse oximetry ≤92%) occurred only in SSP and in older patients (age >50 years) with PSP. Drainage was performed in 150 (67%) PSP and 82 (84%) SSP. Prolonged air leak occurred in 16% (95% confidence interval 10-23%) of PSP and 31% (21-42%) of SSP. Independent risk factors for prolonged drainage were non-asthma SSP and pneumothorax size >50%. Complications were recorded in 11% (7.5-16%) of those having drains inserted. Recurrences occurred in 5/91 (5%, 1.8-12%) of those treated without drainage versus 40/232 (17%, 13-23%) of those treated by drainage, of which half occurred in the first month after drainage.

CONCLUSION

Pneumothorax drainage is associated with substantial morbidity including prolonged air leak. As PSP appears to be well tolerated in younger people even with large pneumothoraces, conservative treatment in this subgroup may be a viable option to improve patient outcomes, but this needs to be confirmed in a clinical trial.

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.

Evaluation of simple aspiration therapy in the initial treatment for primary spontaneous pneumothorax

OBJECTIVE

A retrospective evaluation of the effectiveness of simple aspiration therapy in primary spontaneous pneumothorax was carried out.

METHODS

We enrolled 143 patients with mild and moderate primary spontaneous pneumothorax between June 2006 and October 2010. Clinical backgrounds and therapeutic results from 92 patients that underwent simple aspiration therapy were assessed.

RESULTS

All patients were treated safely without any serious complications. With the exception of one patient with an unknown result, the initial success rate after three days was 72.5% (66 out of 91 patients). Chest X-ray analysis at the first medical examination showed that the success rate was significantly low in patients with a larger vertical rim between the apex and top of the lung and a higher collapsed area ratio; in particular, the success rate was markedly decreased in cases that exceeded 8 cm and 50%, respectively. No significant difference was observed in the aspiration volume, however, the success rate was lower when the aspiration volume was more than 1,500 mL. The recurrence rate at one year was 36.4% (24 out of 66 successfully treated patients).

CONCLUSION

Our results are nearly identical to previous reports from other countries and show that simple aspiration has proved to be a safe and effective therapy.

Evidence-based management of paediatric primary spontaneous pneumothorax

The exact incidence of paediatric primary spontaneous pneumothorax (PSP) is unclear, although PSP incidence in the general population is between 6 and 18 per 100,000. PSP has been reported throughout the paediatric age range. A potential genetic predisposition for familial cases has been recently identified. Whilst there is universal consensus on the management of tension pneumothorax, lack of agreement and consistency exists across a wide range of management issues for other aspects of PSP management. Paediatric PSP may have a higher recurrence rate than adult PSP, and the presence of apical lung cysts or bullae is not predictive of recurrence. The decision for surgical intervention should be based on documented recurrence. There is a lack of paediatric evidence to guide management decisions, and extrapolation of predominantly adult data to younger age groups should not be encouraged. Given the relatively low apparent incidence, a multicentre approach to future research is required in order to generate the evidence required for informed management of PSP in children.