If you’ve watched any television or cinema, you’ve probably seen a violent encounter or two leading to a puncture wound to the chest. The affected party is usually worse for the wear. The suffering is real.
So, if there were a way – if you suffered a pneumothorax – to forgo such an invasion of the thoracic cavity, would you? The U.S. and European guidelines regarding the necessity of such a procedure are not in agreement, and include both chest tube placement and aspiration as options. However, neither explore another option – no intervention. Now, that paradigm may be dramatically altered.
This is a rather simple trial: spontaneous pneumothorax of moderate-to-large (32% or greater, by the Collins method) would be randomized to intervention or conservative management. By intervention, patients would undergo placement of a small-bore chest tube with subsequent observation and discharge or hospital admission as necessary. By conservative, patients were observed in the Emergency Department and discharged unless worsening as defined in the study protocol. The primary outcome was full lung expansion 8 weeks after randomization, with a non-inferiority margin of -9% percentage points.
There were 316 patients randomized, and 25 of the 162 randomized to the conservative management arm underwent an intervention owing to worsening symptoms during initial observation. The remaining cases represented those assessed for outcomes at 8 weeks.
Short story: Success – full expansion in 98.5% with intervention and 94.4% with conservative management.
Long story: If patients with missing data after 56 days were imputed as treatment failures, because more of those in the conservative management arm were lost to follow-up, these data are potentially fallible.
So, this clearly indicates conservative management is probably the preferred course, recognizing a significant number will require an intervention due to early progression. The risk difference is uncertain – or “fragile” – enough the uncertainty regarding management strategies should be shared with patients, in that there could yet be an undefined disadvantage to conservative management. However, it is probably the case patients who did not undergo a drainage procedure and did not return for follow-up were asymptomatic and functioning well. The available data on long-term follow-up even better reinforces the case for conservative management, as need for additional surgical procedures and 12-month recurrences all favored the conservative arm.
These data do not address whether aspiration as an initial strategy has any value, whether in short-term functional improvement or similar long-term outcomes. Considering how well the conservative management cohort did, however, it may ultimately be challenging to show a specific advantage to adding an aspiration procedure. This may perhaps be addressed by future trials.
“Conservative versus Interventional Treatment for Spontaneous Pneumothorax”
Anecdotal evidence to follow. Take it for whatever anecdotal evidence is worth.
A colleague of mine from South Africa showed me a picture of the “Pneumothorax Unit” in the hospital he used to work at. Due to stabbings and genetics they had a continual supply of patients with both traumatic and spontaneous pneumothoraces.
The “Unit” was a large room with about eight beds and four stationary bicycles. Patients were encouraged to vigorously exercise to reinflate their lung parenchyma. Trauma patients got a three-way dressing and the spontaneous pneumothorax patients just got an exercise prescription. X-rays were done daily and patients discharged once radiographic improvement was noted. He relayed that it worked quite well and very few chest tubes were ever placed for isolated pneumothorax.
One of my favorite journal articles is a review of spontaneous pneumothorax treatment by Graham Simpson from 2010, comparing the radical idea of not poking unnecessary holes in the patient vs conventional treatment (a possible descendant of blood-letting).
https://www.ncbi.nlm.nih.gov/pubmed/20446970
There is another article on the use of needle decompression by paramedics to “treat” tension pneumothoraces. Out of 57 patients, only 42 had any puncture anywhere in a lung, in spite of being harpooned by the medic. It is not clear if any of the patients had any lung perforation prior to the medic putting a needle into a lung.
The medics documented that they heard a rush of air as the needle was placed, even for those patients with completely intact lungs.
https://www.ncbi.nlm.nih.gov/pubmed/20733183
This may give us an idea of the “benefit” provided by life-saving treatment of intubation. Most intubations are for cardiac arrest and there is still no evidence of any improvement in outcome with ventilation, as opposed to the passive ventilation provided by continuous chest compressions.
We are certain that we are saving people from death, but how often we are causing more harm with our “treatments”? If we require evidence of benefit before promoting any treatment as the standard of care our patients will probably be much better off.
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