Primary Spontaneous Pneumothorax – Needle Or Not?

Written by Megan Hilbert

Primary spontaneous pneumothorax (PSP) may be most cost-effectively managed by observation alone in the appropriate patient population.

Why does this matter?
The British Thoracic Society guidelines currently indicate placement of pleural drain for symptomatic pneumothorax greater than 2cm in size on chest X-ray. This paper demonstrated that observation (in very specific patients*) may instead be the most effective and lowest cost management strategy.

Take my breath away…no wait, give it back
This was a systematic review and cost utility analysis of management strategies for PSP. Compared was observation, aspiration (needle aspiration or small bore pigtail followed by clamping), and chest tube (14 French or larger with continued suctioning).  The primary measured outcome was resolution of pneumothorax after initial intervention.

Secondary outcomes included rate of pneumothorax recurrence, hospital length-of-stay, rate of surgical management, and complications.

Important general findings:

• Length of stay was shorter with observation compared to chest tube (mean difference 5.17 days, CI:3.75-6.59, p<0.01, I²= 62%).
• Similarly, there was shorter length of stay with aspiration vs chest tube, with mean difference (MD) of 2.72 days (CI: 2.39-3.04 days, p<0.01, I²= 0%, 5 studies).
• Chest tube was, however, more likely to lead to resolution of the PSP (RR 0.81, CI:0.71-0.91, p<0.01, I²= 62%). There was also evidence of aspiration similarly resulting in higher resolution than observation (RR 0.73, CI: 0.61-0.88, p<0.01, I²= 67%).
• Two-year recurrence rates were not statistically significant between the three groups.
• Observation resulted in higher utility with lower cost.

The authors, therefore, suggest a paradigm shift where observation be considered first line for management of PSP followed by aspiration as second line.

There were quite a few limitations:

• *There was no unifying recommendation of what predefined criteria made a patient a more favorable candidate for observation compared to intervention.
• The size of the pneumothorax was not reliably reported in the studies; therefore, management strategies were often at the discretion of the treating provider.
• Cost analysis was based on data from a Canadian health system. The trend of shorter length of stay and less complications should theoretically result in lower health care costs regardless.

Source
Observation, aspiration, or tube-thoracostomy for primary spontaneous pneumothorax: A systematic review, meta-analysis and cost-utility analysis. Chest. 2023 May 18;S0012-3692(23)00756-0. doi: 10.1016/j.chest.2023.05.017. Online ahead of print.