Clinical Question

Is conservative management effective for the treatment of uncomplicated primary spontaneous pneumothorax?

Bottom Line

Conservative observation of patients presenting with a first primary spontaneous pneumothorax is as effective as immediate chest tube insertion in achieving full lung re-expansion at eight weeks. Conservative therapy leads to fewer complications and fewer days in the hospital. (Level of Evidence = 1b−)

Synopsis

Patients who presented to the emergency departments of 39 hospitals in Australia and New Zealand with a unilateral, moderate to large, primary spontaneous pneumothorax were randomized to receive immediate inter vention (n = 154) or conservative observation (n = 162). In the intervention group, patients had a chest tube inserted (water seal for one hour, then clamped for four hours) and were monitored for re-expansion of the lung using chest radiography. If the lung re-expanded and the pneumothorax did not recur, then the chest tube was removed, and the patient was discharged. If the lung did not re-expand or the pneumothorax recurred, the patient was admitted to the hospital. In the conservative group, patients were observed for four hours. Patients whose symptoms were controlled, were walking comfortably, were hemodynamically stable without the need for supplemental oxygen, and had a stable pneumothorax on repeat chest radiography were discharged. Those who required further intervention were managed at the discretion of the treating physician. The mean age in the two groups was 26 years, and 86.1% of the patients were men. There were fewer current smokers in the conservative group (42.5% vs. 49.3%). At eight weeks, 98.5% of the intervention group and 94.4% of the conservative group had complete radiographic resolution of the pneumothorax, satisfying the prespecified noninferiority criteria of −9 percentage points (risk difference = −4.1 percentage points; 95% CI, −8.6 to 0.5; P = .02). Radiologists were less likely than treating physicians to assess that a pneumothorax had completely resolved (radiologists: 91.9% intervention vs. 94.8% conservative; treating physicians: 99.2% intervention vs. 99.1% conservative). Median time to radiographic resolution was shorter in the intervention group (16 days vs. 30 days). Ultimately, 85% of patients in the conservative group did not require any invasive drainage procedures. The conservative group had shorter hospital stays, required fewer days off work, experienced fewer adverse events, and were less likely to have recurrences during the next 12 months.

Study design: Randomized controlled trial (nonblinded)

Funding source: Government

Allocation: Concealed

Setting: Emergency department

Reference: Brown SGA, Ball EL, Perrin K, et al.; PSP Investigators. Conservative versus interventional treatment for spontaneous pneumothorax. N Engl J Med. 2020;382(5):405–415.