EBQ:Conservative versus interventional treatment for spontaneous pneumothorax

incomplete Journal Club Article

Simon G.A. et. al. "Conservative versus Interventional Treatment for Spontaneous Pneumothorax". '. 2020. 382:405-415.
PubMed Full text

Conclusion

• Supports conservative therapy vs chest tube.

Population

Inclusion Criteria

• 14 to 50 years of age
• unilateral primary spontaneous pneumothorax of 32% or more on chest radiography according to the Collins method (sum of interpleural distances, >6 cm)

Exclusion Criteria

• Secondary pneumothorax, defined as pneumothorax occurring in the setting of acute trauma (including iatrogenic) or underlying lung disease including but not limited to COPD, pulmonary fibrosis, TB, cystic fibrosis, lung cancer and asthma that requires regular preventative medication or has been symptomatic within the last two years
• Previous spontaneous pneumothorax on the same side
• Coexistent hemothorax (i.e. spontaneous hemopneumothorax)
• Bilateral pneumothorax
• Clinical instability suggesting tension pneumothorax; respiratory distress persisting despite oxygen and parenteral narcotic analgesia (RR >30/min or SpO2 <90%), SBP <90 mmHg, HR greater than or equal to SBP.
• Pregnancy at time of enrolment
• Social circumstances whereby the patient either does not have adequate support after discharge to re-attend hospital if required, or is unlikely to present for study follow up.
• Air travel within the next 12 weeks if this cannot be deferred should the pneumothorax be slow to resolve

Interventions

• Observed for a minimum of 4 hours then repeat chest X-ray.
• Discharge if no supplementary oxygen and walking comfortably,
• Chest tubes placed if:
  • clinically significant symptoms persisted despite adequate analgesia
  • chest pain or dyspnea prevented mobilization
  • patient was unwilling to continue with conservative treatment
  • the patient’s condition became physiologically unstable (systolic blood pressure of <90 mm Hg, heart rate in beats per minute greater than or equal to systolic blood pressure in millimeters of mercury, respiratory rate of >30 breaths per minute, or Spo2 of <90% while the patient was breathing ambient air)
  • Repeat chest radiograph showed an enlarging pneumothorax along with physiological instability.

Criticisms & Further Discussion

• Significant drop out rate
• Relatively large number of protocol violations
• large inferiority margins and the short intervention time.”

See Also

• Spontaneous pneumothorax