https://pubmed.ncbi.nlm.nih.gov/31995686/
Clinical Trial
Reference: Brown SGA, Ball E, Perrin K, et al. Conservative versus Interventional Treatment for Spontaneous Pneumothorax. NEJM 2020; 382(5):405–415. doi:10.1056/NEJMoa1910775.
Background: Traditionally, moderate-to-large primary spontaneous pneumothorax are managed with interventions such as aspiration or chest tube. This study evaluated whether conservative management was an acceptable alternative to interventional management for uncomplicated, moderate-to-large primary spontaneous pneumothorax.
PICO:
Populations:
- Randomized 316 patients aged 14 to 50 years with first occurrence of a unilateral moderate-to-large primary spontaneous pneumothorax
- Patients followed for 12 months
Intervention:
- Immediate interventional management of pneumothorax (n=154)
Comparison:
- Conservative observational management of pneumothorax (n=162)
- These patients could undergo an intervention for pre-specified criteria in the protocol
Outcome:
- Primary outcome: Conservative management was found to be non-inferior to immediate interventional management in complete case analysis.
- In a sensitivity analysis where all missing data was imputed as treatment failure, the risk difference of conservative management vs. immediate interventional management was outside the pre-specified non-inferiority margin
- Conservative management resulted in lower risk of serious adverse events or pneumothorax recurrence when compared to interventional management
Take Home: This trial provides some evidence that conservative management of the initial occurrence of a moderate-to-large unilateral primary spontaneous pneumothorax may be a reasonable option with fewer serious adverse events when compared to immediate interventional management.
A Systematic Review of Digital vs Analog Drainage for Air Leak After Surgical Resection or Spontaneous Pneumothorax
https://pubmed.ncbi.nlm.nih.gov/31958444/
Review
Reference: Aldaghlawi F, Kurman J, Lilly J, et al. A Systematic Review of Digital vs. Analog Drainage for Air Leak After Surgical Resection or Spontaneous Pneumothorax. CHEST. 2020; 157(5):1346-1353.
Summary: This review sought to assess the impact of digital drainage on chest tube duration and hospital LOS after pulmonary surgery and spontaneous pneumothorax. Twenty-three articles were included in the review, four pertaining to air leak after spontaneous pneumothorax and 19 addressing postoperative air leak. Digital drainage resulted in significantly shorter chest tube duration in 8/18 studies and shorter hospital LOS in 6/14 studies for postoperative air leak. For pneumothorax air leak, digital drainage resulted in significantly shorter chest tube duration in 2/3 studies and hospital LOS in 1/2 studies. Most studies did not show a difference in chest tube duration or hospital LOS with digital vs. analog drainage systems for air leak post-lung resection, but digital drainage systems may be beneficial in post-spontaneous pneumothorax air leak.
Secondary spontaneous pneumothorax in cancer patients
https://pubmed.ncbi.nlm.nih.gov/31179092/
Retrospective
Reference: Grosu HB, Vial M, Hernandez M, et al. Secondary Spontaneous Pneumothorax in Cancer Patients. J Thorac Dis 2019; 11(4):1495-1505. doi: 10.21037/jtd.2019.03.35.
Summary: Malignancy-associated secondary spontaneous pneumothorax poses a unique problem given these patient’s limited life expectancy. This was a retrospective cohort study of patients with malignancy-associated secondary spontaneous pneumothorax that evaluated time to and risk factors for pneumothorax recurrence. The goal of this study was to identify patients who could benefit from early intervention to prevent recurrence. Ninety-six patients were included in the time-to-event analysis, 9.4% of which experienced pneumothorax recurrence. The estimated cumulative incidence of pneumothorax was 10.1% at 15 months, using death as a competing risk. This study found that mediastinal shift, distance from lung apex to thoracic cupola and distance between visceral pleura and chest wall at the hilum were associated with malignancy-associated secondary spontaneous pneumothorax recurrence. Sarcoma was also associated with an increased risk of recurrence.
A Systematic Review and Meta-Analysis Comparing Pigtail Catheter and Chest Tube as the Initial Treatment for Pneumothorax
https://pubmed.ncbi.nlm.nih.gov/29452099/
Review
Reference: Change SH, Kang YN, Chiu HY, Chiu YH. A Systematic Review and Meta-Analysis Comparing Pigtail Catheter and Chest Tube as the Initial Treatment for Pneumothorax. CHEST. 2018; 153(5):1201-1212.
Summary: This review and meta-analysis investigated the effectiveness of small-bore pigtail catheter drainage compared with large-bore chest tube drainage as the initial treatment for pneumothorax. It evaluated success rates, recurrence rates, complication rates, drainage duration and hospital LOS. The success rate was similar in the two groups but pigtail catheter drainage was associated with a significantly lower complication rate when compared to large-bore chest tube drainage in patients with spontaneous pneumothorax. Pigtail catheter drainage was also associated with a significantly shorter drainage duration and hospital LOS when compared to large-bore catheters. Pigtail catheter drainage may be a good initial treatment option for patients with primary and secondary spontaneous pneumothorax.
Ambulatory management of primary spontaneous pneumothorax: an open-label, randomised controlled trial
https://pubmed.ncbi.nlm.nih.gov/32622394/
Clinical Trial
Reference: Hallifax RJ, McKeown E, Sivakumar P, et al. Ambulatory management of primary spontaneous pneumothorax: an open-label, randomised controlled trial. Lancet. 2020;396(10243):39-49.
Background: This is an open label, randomized controlled trial evaluating the efficacy of ambulatory management in patients with primary spontaneous pneumothorax.
PICO:
Population –
- Adult patients (16-55 years old) with symptomatic primary spontaneous pneumothorax were included (n=236)
Intervention –
- Standard guideline-based management (aspiration, chest tube thoracostomy) (n=119)
Comparison –
- Ambulatory device (n=117)
Outcome –
- The primary outcome was the total length of hospitalization including readmission up to 30 days after randomization. At day 30, the median hospitalization was significantly shorter in the ambulatory device group (0 days [IQR 0-3]) than the standard of care group (4 days [IQR 0-8]; p < 0.0001).
- Fifty-five percent of patients in the ambulatory device group and 39% of patients in the standard of care group experienced adverse events. All of the serious adverse events (n = 14, enlarging pneumothorax, asymptomatic pulmonary edema, device malfunction, leaking or dislodging) occurred in the ambulatory device group.
Take home: In patients with primary spontaneous pneumothorax, ambulatory device management decreases the need for inpatient hospitalization but has an increased risk of adverse events compared to standard of care.
Ambulatory management of secondary spontaneous pneumothorax: a randomised controlled trial
https://pubmed.ncbi.nlm.nih.gov/33334938/
Clinical Trial
Reference: Walker SP, Keenan E, Bintcliffe O, et al. Ambulatory management of secondary spontaneous pneumothorax: a randomised controlled trial. Eur Respir J. 2021;57(6):2003375.
Background: This is an open label, randomized controlled trial evaluating outcomes of patients undergoing chest tube placement for secondary spontaneous pneumothorax managed with either ambulatory care with flutter valve or standard management.
PICO:
Population –
- Adult patients receiving chest tubes for secondary spontaneous pneumothorax (n = 41)
Intervention –
- Ambulatory care with flutter valve (n = 21)
Comparison –
- Standard of care (chest tubes placed on water seal) (n = 20)
Outcome –
- The primary outcome was hospital length of stay. There was no difference between ambulatory care (median 6 days, IQR 14.5) versus standard of care (median 6 days, IQR 13.3) at 30 days
- Pleural vents had a high rate of early treatment failure, defined as requiring further pleural intervention in the first week, (46%) compared to standard of care (15%) (p = 0.11)
- Atrium pneumostats did not have early treatment failures (0%)
Take home: There is no difference in hospital length of stay between ambulatory care versus standard of care in patients undergoing chest tube thoracostomy for secondary spontaneous pneumothorax. Pleural vents may not be safe in patients with secondary spontaneous pneumothorax due to high rates of early treatment failure.
