Outcomes of Emergency Department Patients Treated for Primary Spontaneous Pneumothorax

doi:10.1378/chest.08-0910

Chest

Volume 134, Issue 5, November 2008, Pages 1033-1036

https://doi.org/10.1378/chest.08-0910 Get rights and content

Background

International guidelines for the management of primary spontaneous pneumothorax (PSP) vary, and there is growing opinion that more patients could be successfully managed with observation alone. There is little published evidence detailing the outcomes of emergency department (ED) patients who have been treated for PSP. The aim of this study was to describe the clinical outcomes for patients with PSP.

Methods

This was a retrospective cohort study that was conducted by explicit medical record review that investigated adult patients with PSP who had been treated at two urban teaching hospital EDs from 1996 to 2005. The data collected included demographics, clinical data at presentation, and outcome data. The outcome of interest was the proportion of patients who were successfully treated with the initial management strategy (ie, conservative, aspiration, and tube thoracostomy). Data analysis was performed using descriptive statistics.

Results

A total of 203 episodes of PSP in 154 patients (70% male; median age, 24 years) was identified. PSP size ranged from 5 to 100%. Ninety-one PSP patients (45%) were treated with outpatient observation, 48 patients (24%) were treated with aspiration, and 64 patients (31%) were treated with tube thoracostomy. In total, the conditions of 79% of patients (82 of 91 patients) who were treated with observation resolved without additional intervention. Aspiration was successful in 50% of cases (24 of 48 cases) where it was attempted; the conditions of 73% of PSP patients who were treated with tube thoracostomy (47 of 64) resolved without additional intervention.

Conclusion

These data suggest that observation alone is an effective initial treatment strategy for selected patients with PSP. They support the inclusion of an observation arm in planned prospective studies comparing different management approaches.

Section snippets

Study Design

This was a retrospective observational cohort study that was conducted by explicit medical record review.⁵

Setting

The study was conducted in two community teaching hospitals in Melbourne, VIC, Australia.

Participants

The participants in the study consisted of a consecutive sample of adult ED patients (age range, 16 to 60 years) with confirmed PSP who were treated from 1996 to 2005 and were identified from an ED administrative database. Patients with secondary iatrogenic and traumatic pneumothoraces were excluded

Results

There were 203 episodes of PSP in 154 patients. Patient characteristics are shown in Table 1. Fifty-five percent of patients were documented as being current smokers. PSP size ranged from 5 to 100%, with 57% occurring on the left side. In 38% of episodes (78 of 203 episodes), patients reported having experienced a previous PSP; 67% of episodes (51 episodes) occurred on the same side, and a further 12% of episodes (9 episodes) occurred on both sides. It was not possible to calculate the

Discussion

The optimal management strategy for clinically well patients with PSP remains to be defined. Guidelines vary in their recommendations (Table 2), and a robust evidence base to inform practice is lacking.

Our data suggest that conservative management is successful in a high proportion of selected patients (79%), including those with larger PSPs. There were no emergent interventions, suggesting that this approach is also safe. This is only the second series of > 50 patients reporting outcomes for

Conclusion

These data suggest that outpatient observation is an effective initial treatment strategy in selected patients with PSP. They support the inclusion of an observation arm in planned prospective studies comparing management approaches.

References (13)

MH Baumann et al.
Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement
Chest
(2001)
EH Gilbert et al.
Chart reviews in emergency medicine research: where are the methods?
Ann Emerg Med
(1996)
JP O'Rourke et al.
Civilian spontaneous pneumothorax: treatment options and long-term results
Chest
(1989)
M Henry et al.
BTS guidelines for the management of spontaneous pneumothorax
Thorax
(2003)
P De Leyn et al.
Guidelines Belgian Society of Pulmonology: guidelines on the management of spontaneous pneumothorax
Acta Chir Belg
(2005)
AM Kelly
Management of primary spontaneous pneumothorax: is the best evidence clearer fifteen years on?
Emerg Med Australas
(2007)

There are more references available in the full text version of this article.

Cited by (48)

Observation, Aspiration, or Tube Thoracostomy for Primary Spontaneous Pneumothorax: A Systematic Review, Meta-Analysis, and Cost-Utility Analysis
2023, Chest
Primary spontaneous pneumothorax (PSP) has several commonly used management strategies: observation, aspiration, and chest tube placement. Economic modelling of pooled data comparing techniques has not been performed.
Based on studies from the past 20 years, which approach to management of PSP delivers the highest utility?
A systematic review of PSP management strategies (observation, aspiration, or chest tube placement) included in the Medline and EMBASE databases from January 1, 2000, through April 10, 2020, was conducted. Text screening, bias assessment, and data extraction were performed by two authors (G. E. and C. A. P.). Inclusion and exclusion criteria were defined a priori. The primary outcome was PSP resolution after the initial intervention. Secondary outcomes were PSP recurrence, length of stay, rate of surgical management, and complications. The meta-analysis compared treatment arms; dichotomous outcomes were reported as relative risk (RRs) and continuous outcomes were reported as mean differences. A cost-utility analysis within the Canadian health care system context with deterministic and probabilistic sensitivity analyses was performed.
Five thousand one hundred seventy-nine articles were identified; after screening, 22 articles were included. Most trials showed a high risk of bias, but randomized trials showed a lower risk. Compared with chest tube placement, observation (mean difference, 5.17; 95% CI, 3.75-6.59; P < .01; I² = 62%) and aspiration (mean difference, 2.72; 95% CI, 2.39-3.04; P < .01; I² = 0%) showed a shorter length of stay. Compared with observation, chest tube placement (RR, 0.81; 95% CI, 0.71-0.91; P < .01; I² = 62%) and aspiration (RR, 0.73; 95% CI, 0.61-0.88; P < .01; I² = 67%) showed higher resolution without additional intervention. Two-year recurrence rates did not differ between management strategies. Observation showed the best utility (0.82) and lowest cost; observation was the optimal strategy in 98.2% of Monte Carlo simulations.
Observation is the dominant choice compared with aspiration and chest tube placement for PSP. It should be considered as the first-line therapy in appropriately selected patients.
Utilization and Outcomes of Observation for Spontaneous Pneumothorax at an Integrated Health System
2023, Journal of Surgical Research
Though limited, recent evidence supports observation rather than intervention for spontaneous pneumothorax management. We sought to compare the utilization and outcomes between observation and intervention for patients with primary and secondary spontaneous pneumothoraces.
A retrospective cohort study of all adults presenting to Kaiser Permanente Northern California emergency rooms with spontaneous pneumothorax from 2016 to 2020 was performed. Those with prior pneumothoraces, tension physiology, bilateral pneumothoraces, effusions, and prior thoracic procedures or surgery on the affected side were excluded. Groups included observation versus intervention. Baseline clinicodemographic variables and outcomes were compared. Treatment was considered successful if further interventions were not required for pneumothorax resolution. Wilcoxon rank-sum tests, chi-square tests, Fischer exact tests, and multivariable logistic regression models were performed.
Of the 386 patients with primary spontaneous pneumothorax, age, race/ethnicity, body mass index, smoking status, and the Charlson comorbidity index were not different between treatment groups. Of 86 patients with secondary spontaneous pneumothorax, age, gender, and smoking status were not different between treatment groups. Among patients with primary pneumothoraces, 83 underwent observation while 303 underwent intervention. The success rate was 92.8% for observation and 60.4% for intervention (P < 0.0001). Among patients with secondary pneumothoraces, 15 underwent observation while 71 underwent intervention, with a successful rate of 73.3% for observation and 32.4% for intervention (P = 0.003).
Given the high success rates for observation of both small and moderate primary and secondary pneumothoraces, observation should be considered for clinically stable patients. Observation may be the superior choice for decreasing morbidity and healthcare costs.
SPLF/SMFU/SRLF/SFAR/SFCTCV Guidelines for the management of patients with primary spontaneous pneumothorax: Endorsed by the French Speaking Society of Respiratory Diseases (SPLF), the French Society of Emergency Medicine (SFMU), the French Intensive Care Society (SRLF), the French Society of Anesthesia & Intensive Care Medicine (SFAR) and the French Society of Thoracic and Cardiovascular Surgery (SFCTCV)
2023, Respiratory Medicine and Research
Primary spontaneous pneumothorax (PSP) is the presence of air in the pleural space, occurring in the absence of trauma and known lung disease. Standardized expert guidelines on PSP are needed due to the variety of diagnostic methods, therapeutic strategies and medical and surgical disciplines involved in its management.
Literature review, analysis of literature according to the GRADE (Grading of Recommendation Assessment, Development and Evaluation) methodology; proposals for guidelines rated by experts, patients, and organizers to reach a consensus. Only expert opinions with strong agreement were selected.
A large PSP is defined as presence of a visible rim along the entire axillary line between the lung margin and the chest wall and ≥2 cm at the hilum level on frontal chest x-ray. The therapeutic strategy depends on the clinical presentation: emergency needle aspiration for tension PSP; in the absence of signs of severity: conservative management (small PSP), needle aspiration or chest tube drainage (large PSP). Outpatient treatment is possible if a dedicated outpatient care system is previously organized. Indications, surgical procedures and perioperative analgesia are detailed. Associated measures, including smoking cessation, are described.
These guidelines are a step towards PSP treatment and follow-up strategy optimization in France.
Guidelines for management of patients with primary spontaneous pneumothorax
2023, Revue des Maladies Respiratoires
The Primary Spontaneous Pneumothorax trial: A critical appraisal from the surgeon's perspective
2021, Journal of Thoracic and Cardiovascular Surgery
Comparison of efficiency and safety of conservative versus interventional management for primary spontaneous pneumothorax: A meta-analysis
2021, American Journal of Emergency Medicine
Citation Excerpt :
All included studies compared conservative management with interventional treatment, four studies with chest-tube drainage, one study with needle aspiration, one study with chest-tube drainage and needle aspiration, one study with chest-tube drainage and VATS and one study with Thoracotomy and VATS. In general, six included studies involving 890 patients reported success rates [7,11,12,14,15,17]. There was no statistically significant difference in success rates between conservative management (258 of 292 [88.36%]) group and interventional management (505 of 598 [84.45%]) group (risk ratio 1.05, 95% confidence interval 0.94 to 1.17, I2 = 69.1%; Fig. 2).
There is growing opinion that primary spontaneous pneumothorax (PSP) patients without hemodynamic compromise could be safely and successfully managed with observation alone. The aims of this meta-analysis were to estimate the safety and effectiveness of conservative treatment compared with that of interventional management as the initial treatment option for patients with PSP.
The PubMed, Embase and Cochrane library databases were systematically searched for randomized controlled trials (RCTs) and cohort studies (prospective or retrospective) until April 25, 2020, that compared conservative treatment and interventional treatment as the initial treatment for patients with PSP. The primary outcomes were success rates and recurrence rates. The secondary outcome was complication rates. Data extraction and quality assessment from eligible studies were independently conducted by two reviewers.
8 trials with a total of 1342 patients were identified. The success rates of conservative management were similar with interventional treatment, with a risk ratio 1.05 (95% confidence interval 0.94 to 1.17, I2 = 69.1%). There was no significant difference of recurrence rates between these two type managements. (RR, 1.43, 95% confidence interval 0.45 to 4.55, I2 = 86.7%). Complication rates were lower in conservative treatment group (13 of 215 [6.05%]) than in interventional treatment group (57 of 212, [26.89%]), although the difference did not reach statistical significance (RR, 0.15, 95% CI, 0.02 to 1.13, I2 = 56.7%).
Results of the meta-analysis suggest that conservative treatment offers a safe and effective alternative as compared with interventional management as the initial treatment approach for patients with PSP. However, more randomized clinical trials are need to provide more strong evidence to confirm our results.

View all citing articles on Scopus

The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

View full text

Chest

Original ResearchSpontaneous PneumothoraxOutcomes of Emergency Department Patients Treated for Primary Spontaneous Pneumothorax

Background

Methods

Results

Conclusion

Section snippets

Study Design

Setting

Participants

Results

Discussion

Conclusion

Chest

Ann Emerg Med

Chest

BTS guidelines for the management of spontaneous pneumothorax

Thorax

Guidelines Belgian Society of Pulmonology: guidelines on the management of spontaneous pneumothorax

Acta Chir Belg

Management of primary spontaneous pneumothorax: is the best evidence clearer fifteen years on?

Emerg Med Australas

Original Research
Spontaneous Pneumothorax
Outcomes of Emergency Department Patients Treated for Primary Spontaneous Pneumothorax