Watch-and-wait strategy is an option for primary spontaneous pneumothorax

Reference

Brown SGA, Ball EL, Perrin K, et al, for the PSP Investigators. Conservative versus interventional treatment for spontaneous pneumothorax. N Engl J Med 2020;382(5):405-415.

Synopsis

Patients who presented to the emergency departments of 39 hospitals in Australia and New Zealand with a unilateral, moderate-to-large, primary spontaneous pneumothorax were randomized to receive either immediate intervention (n = 154) or conservative observation (n = 162). In the intervention group, patients had a chest tube inserted (water seal for 1 hour, then clamped for 4 hours) and were monitored for re-expansion of the lung using chest radiography. If the lung re-expanded and the pneumothorax did not recur, then the chest tube was removed and the patient was discharged. If, however, the lung did not re-expand or the pneumothorax recurred, then the patient was admitted to the hospital. In the conservative group, patients were observed for 4 hours. Patients whose symptoms were controlled, were walking comfortably, were hemodynamically stable without the need for supplemental oxygen, and had a stable pneumothorax on repeat chest radiography were discharged. Those who required further intervention were managed at the discretion of the treating physician. Overall, 86.1% of the patients in the 2 groups were men and the mean age was 26 years. There were fewer current smokers in the conservative group (42.5% vs 49.3%). At 8 weeks, 98.5% of the intervention group and 94.4% of the conservative group had complete radiographic resolution of the pneumothorax, satisfying the pre-specified noninferiority criteria of -9 percentage points (-4.1 percentage points; 95% CI -8.6 to 0.5; P = .02). Radiologists were less likely than treating physicians to assess that a pneumothorax had completely resolved (radiologists: 91.9% intervention vs 94.8% conservative; treating physicians: 99.2% intervention vs 99.1% conservative). Median time to radiographic resolution was shorter in the intervention group (16 days vs 30 days). Ultimately, 85% of patients in the conservative group did not require any invasive drainage procedures. Additionally, the conservative group had shorter hospital stays, required fewer days off work, experienced fewer adverse events, and were less likely to have recurrences during the next 12 months.