Pneumothorax

Pneumothorax

Conservative versus Interventional Treatment for Spontaneous Pneumothorax

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.


 Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010

https://www.ncbi.nlm.nih.gov/pubmed/20696690

Guideline 

Reference: Macduff A, Arnold A, Harvey J. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65 Suppl 2:ii18-31.

Summary: These guidelines describe the clinical evaluation and recommended imaging for patients presenting with suspected pneumothorax. It also details the treatment options for primary and secondary spontaneous pneumothorax. In addition, this article discusses the diagnosis and management of specific etiologies of pneumothorax.


 Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement

https://pubmed.ncbi.nlm.nih.gov/11171742/

Guideline 

Reference: Baumann M, Strange C, Heffner JE, et al. Management of Spontaneous Pneumothorax: An ACCP Delphi Consensus Statement. CHEST 2001; 119:590-602.

Summary: This consensus statement provides recommendations for the management of adults with primary and secondary spontaneous pneumothoraces in the emergency department or inpatient hospital setting. The management varies depending on whether the patient has experienced a primary or secondary spontaneous pneumothorax as well as the size and clinical symptoms.