Is it time to approach spontaneous pneumothorax more conservatively?
A recent study provides modest evidence for observational management over interventional treatment, sparing patients from invasive procedures.
PRACTICE CHANGER
Consider observation rather than chest tube placement for primary, uncomplicated, unilateral moderate-to-large spontaneous pneumothorax in patients ages 14 to 50.
STRENGTH OF RECOMMENDATION
B: Based on a single, lower-quality randomized controlled trial1
Brown SGA, Ball EL, Perrin K, et al; PSP Investigators. Conservative versus interventional treatment for spontaneous pneumothorax. N Engl J Med. 2020;382:405-415. doi: 10.1056/NEJMoa1910775
WHAT’S NEW
Conservative management enabled most patients to avoid invasive Tx risks
In this specific patient population, conservative management of primary spontaneous pneumothorax was noninferior to interventional management and had a lower risk of serious adverse events. This management practice spared 85% of the patients from invasive intervention. As a result, they experienced a shortened hospital stay, fewer days missed from school or work, less exposure to radiation from repeat chest x-rays, and a lower rate of adverse events. Additionally, fewer of these patients had early pneumothorax recurrence.
CAVEATS
There were limitations in the trial’s original statistical design
This study had a specific follow-up timetable, and some of the participants were not examined until after the 8-week checkpoint or were lost to follow-up entirely. The authors attempted to address these limitations (and show transparency) by providing additional sensitivity analyses as well as providing the intention-to-treat and per-protocol analyses for the primary outcome at 8 weeks. Noninferiority was maintained in all analyses except for the sensitivity analysis that treated missing data as treatment failure. Therefore, the authors note these approaches result in “statistical fragility” and are exploratory.
CHALLENGES TO IMPLEMENTATION
Pneumothorax is not commonly seen in outpatient settings
Family physicians working in outpatient settings generally do not encounter pneumothorax and, using current guidelines, would refer for emergency or inpatient care. This study opens the possibility of managing selected patients in an outpatient setting; however, this would require at least a 4-hour period of observation, which may be impractical for many outpatient-based physicians. Additionally, the study uses the Collins method to define moderate-to-large pneumothorax, which is likely an uncommon practice and thus not applicable in most primary care settings.
ACKNOWLEDGEMENT
The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center for Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.
