Deficiencies of management of spontaneous pneumothoraces

Generalist vs specialist acute medical admissions - What is the impact of moving towards acute medical subspecialty admissions on efficacy of care provision?

INTRODUCTION

The discussion surrounding generalist versus specialist acute medical admissions continues to stimulate debate and patients with certain conditions benefit from specialist care.

AIM

To determine whether a specialty medical admission program would reduce inpatient length of stay (LOS), mortality and readmission rates.

DESIGN/METHODS

A prospective cohort study of inpatients admitted under a general internal medicine (GIM) service before and after introduction of a specialty-directing programme. We hypothesized that early transfer of patient care to a specialty suited to their presenting complaint would reduce LOS and a specialty-directing early redistribution of care programme was introduced. Seven of the ten clinical teams participating in the GIM roster adopted the programme. On the morning following a specialty-directing team being on call for all new GIM admissions during a 24-hour period, specialty-directing teams were allocated one patient appropriate to their specialty.

RESULTS

5,144 patient-care episodes were analysed over the two-year study period. LOS increased by greater than 15%, one year after introducing the specialty-directing programme (8.5±8.4 vs 7.3±7.5 days, p < 0.001). LOS did not differ between teams that participated and those who did not (8.4±8.1 vs 8.1±7.9 days, p = 0.298). No differences were found in the proportion of patients who were discharged home, died while an inpatient or re-admitted within 30 days of discharge. The proportion of patients aged greater than 80 years increased significantly also - from 24.7% in 2017 to 27.9% in 2019(p == 0.009).

CONCLUSION

Widespread adoption of specialist care may not be beneficial for all medical inpatients and physicians should continue to undergo dual specialist and GIM training.

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.

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

BACKGROUND

In the management of primary spontaneous pneumothorax, simple aspiration is technically easier to perform. A systematic review may better define the clinical effectiveness and safety of simple aspiration compared to intercostal tube drainage in the management of primary spontaneous pneumothorax.

OBJECTIVES

To compare the clinically efficacy and safety of simple aspiration and intercostal tube drainage in the management of primary spontaneous pneumothorax.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2006), MEDLINE (1966 to August 2006), and EMBASE (1980 to August 2006). We searched Current Controlled Trials metaRegister of Clinical Trials (compiled by Current Science) (August 2006). We checked the reference lists of trials and contacted trial authors . We imposed no language restriction.

SELECTION CRITERIA

Randomized controlled trials comparing simple aspiration with intercostal tube drainage in adults aged 18 and over with primary spontaneous pneumothorax.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. No statistical methods were necessary because only one study met the inclusion criteria.

MAIN RESULTS

Of the 1239 publications obtained from the search strategy, we examined six studies. Five studies were excluded, and one study of 60 participants was eligible for inclusion. There was no difference in immediate success rate of simple aspiration when compared with intercostal tube drainage in the management of primary spontaneous pneumothorax (relative risk (RR) = 0.93; 95% confidence interval (CI) 0.62 to 1.40). There was no significant difference in the early failure rate between the two interventions: RR 1.12 (95% CI 0.59 to 2.13). Simple aspiration reduced the proportion of patients hospitalized (RR = 0.52; 95% CI 0.36 to 0.75). There was no significant difference between the two interventions with regard to the following outcome measures: duration of hospitalization (weighted mean difference = 1.09; 95% CI 2.18 to 0.00); number of participants undergoing any procedure for lung pleurodesis within one year (RR = 0.95; 95% CI 0.41 to 2.22);and one year success rate (RR = 1.02; 95% CI 0.75 to 1.38).

AUTHORS' CONCLUSIONS

There is no significant difference between simple aspiration and intercostal tube drainage with regard to: immediate success rate, early failure rate, duration of hospitalisation, one year success rate and number of patients requiring pleurodesis at one year. Simple aspiration is associated with a reduction in the per cent of patients hospitalized when compared with intercostal tube drainage.

Simple aspiration as initial treatment for primary spontaneous pneumothorax: Results of 91 consecutive cases

Varying opinions exist regarding the choice of initial treatment for primary spontaneous pneumothorax (PSP). This study aims to determine the success rate of simple aspiration of PSP, identify factors associated with failure, and identify associated complications. A retrospective analysis was performed on 91 consecutive patients receiving simple aspiration for PSP at the Emergency Department of a university teaching hospital in Hong Kong, China. The overall success rate was 50.5%. Failed cases had significantly larger sizes of pneumothorax, and significantly larger volumes of air aspirated. Pneumothorax size > or =40% was significantly associated with failure. In a multivariate analysis, pneumothorax size > or =40%, compared to size 21-39%, independently predicted failure, with an odds ratio of 8.88 (95% CI, 2.49 to 31.63). Complications were rarely encountered. It is concluded that the success rate may be significantly improved by excluding patients with pneumothorax size 40% or larger from this modality of treatment.

Simple aspiration versus chest-tube insertion in the management of primary spontaneous pneumothorax: a systematic review

BACKGROUND

The initial treatment of a primary spontaneous pneumothorax (PSP) is controversial. Guidelines of the British Thoracic Society recommend simple aspiration for all PSP requiring intervention. The placement of chest tubes is only advocated for patients who fail simple aspiration. However, the American College of Chest Physicians Delphi Consensus Statement found simple aspiration to be rarely appropriate in the management of PSP.

AIMS

To compare simple aspiration with chest-tube drainage in the initial management of PSP.

METHODS

Meta-analysis of randomized controlled trials (RCTs).

OUTCOME MEASURES

Reductions in duration of hospital stay, recurrence rate and pain or dyspnoea score were classified as benefits, whereas reductions in successful events were classified as risks.

DATA COLLECTION AND ANALYSIS

For dichotomous data, the relative risk (RR) and 95% confidence intervals were calculated. For continuous data, weighted mean differences (WMD) were used.

RESULTS

Three RCTs were identified with a combined total of 194 patients. Simple aspiration was associated with shorter hospitalization (WMD -1.30 days [-2.20 to -0.39]). The results for success rate could not be combined because of differences in outcome definitions. However, a pooled result for "success at 1 week or more" showed no significant difference between either intervention (RR 0.86 [0.67, 1.11]). Results of recurrence at 1 year were also not significantly different (RR 0.73 [0.39-1.38]). Different reporting systems for pain scores meant that data could not be pooled. Only one trial reported dyspnoea scores.

CONCLUSION

RCT evidence in this field is limited, and the total sample size is too small to make any firm conclusion. On the basis of current available evidence, simple aspiration is advantageous in the initial management of PSP because of shorter hospitalization. There is no significant difference in recurrence at 1 year using either modality, and the efficacy data are inconclusive.

Management of spontaneous pneumothorax: are British Thoracic Society guidelines being followed?

In 1993, the British Thoracic Society (BTS) issued guidelines for the management of spontaneous pneumothorax. The aim of this study was to determine the level of adherence to and awareness of these guidelines at a London teaching hospital. A retrospective case note audit of 59 episodes of acute spontaneous pneumothorax was performed. In patients undergoing intervention, the initial procedure was simple aspiration in 32 (73%) and chest tube insertion in 12 (27%) cases, contrasting with the BTS recommendation that aspiration should be attempted first in all such patients. Simple aspiration was successful on 34% of occasions. Successful aspiration was associated with a significantly shorter hospital stay (median 3, range 1-11 days) than either failed aspiration (7, 3-66 days; p=0.003) or chest tube insertion without aspiration (9, 3-16 days; p=0.005). Other areas where practice differed from the BTS guidelines were clamping of chest tubes and use of a pursestring suture for wound closure. A follow up questionnaire survey suggested a lack of familiarity with the guidelines. These findings indicate that current management of spontaneous pneumothorax deviates from the BTS guidelines in a number of potentially important respects. Attention should be directed to improving awareness of and access to clinical guidelines.

British Thoracic Society guidelines for the management of spontaneous pneumothorax: do we comply with them and do they work?

OBJECTIVES

To determine how British Thoracic Society (BTS) guidelines for the management of spontaneous pneumothorax have been implemented over a four year period in a large district general hospital with a specialised respiratory unit. To assess the validity of the guidelines in the management of spontaneous pneumothorax.

METHODS

A retrospective case notes study over a four year period for all patients with spontaneous pneumothoraces attending the accident and emergency (A&E) department of a large district general hospital.

RESULTS

115 episodes of spontaneous pneumothorax were identified. Overall 20.8% of episodes were treated correctly by BTS guidelines. Decisions made by A&E staff were significantly more likely to be correct than decisions made by on call medical teams (39.4% v 13.4%, p = 0.002). There was a non-significant trend towards better compliance with BTS guidelines over the four year period. The management decision was made by A&E staff only in 28.7% of episodes. Patients without chronic lung disease could be safely observed as outpatients. Forty three pneumothoraces were aspirated: 23 (58%) successfully; eight (18.6%) with little or no improvement; and 12 (27.9%) initially successfully but developing increased size of pneumothorax within a period of 72 hours. Three patients had repeat aspirations, two successfully. Age over 50, chronic lung disease, and more than 2.5 litres of air aspirated were significantly associated with failure of aspiration (p < 0.01). There was a 28.6% failure rate of aspiration for patients with moderate pneumothoraces without chronic lung disease.

CONCLUSIONS

Patients over the age of 50 should be treated the same as patients with chronic lung disease. A second aspiration should be attempted if the first aspiration is initially successful with subsequent recurrence of pneumothorax. Further research is required to clarify if patients with moderate pneumothoraces under the age of 50 and no chronic lung disease should be aspirated or observed.