Washington University Emergency Medicine Journal Club– August 2023
Vingnette:
You are working a shift in TCC when you get a page that a patient is being moved up
from EM2 for chest tube placement. When the patient arrives, you are introduced to
Mr. B, a thin, healthy 35-year-old male who presented with sudden-onset pleuritic
chest pain earlier that afternoon. He has been hemodynamically stable on room air
since his arrival and is breathing comfortably on your assessment. Thoracic surgery
has been consulted and is planning for placement of a small-bore percutaneous
chest tube for decompression (i.e. a Thal-Quick device).
While preparing for the procedure you come across a previous journal club
discussion from 2008 on simple aspiration or Heimlich valve placement as an
alternative to chest tube drainage for primary spontaneous pneumothorax.
Wondering whether there has been any new data on this topic in the intervening 15
years, you begin a dive into the medical literature…
PICO Question
Population: Adult patients with spontaneous (atraumatic) pneumothorax with
hemodynamic stability and no signs of tension physiology
Intervention: Simple needle aspiration
Comparison: Chest tube drainage (include small bore, indwelling chest tubes)
Outcome: Initial success, treatment failure requiring alternative treatment modality,
need for hospital admission, hospital length of stay, short-term recurrence, patient
satisfaction, procedural complications
Search Strategy
A meta-analysis was identified from the Cochrane Database of Systematic Reviews.
As the literature search for this review was conducted in January 2017, PubMed was
searched from 1/1/17 to present (on 8/1/2023) using the terms “spontaneous
pneumothorax” AND aspiration (https://tinyurl.com/yck7vr5a). This resulted in 66
citations, from which 3 randomized controlled trials were identified.
Article 1: Marx T, Joly LM, Parmentier AL, et al. Simple Aspiration versus Drainage
for Complete Pneumothorax: A Randomized Noninferiority Trial. Am J Respir Crit
Care Med. 2023 Jun 1;207(11):1475-1485. Answer Key.
Article 2: Carson-Chahhoud KV, Wakai A, van Agteren JE, Smith BJ, McCabe G, Brinn
MP, O’Sullivan R. Simple aspiration versus intercostal tube drainage for primary
spontaneous pneumothorax in adults. Cochrane Database Syst Rev. 2017 Sep
7;9(9):CD004479. Answer Key.
Article 3: Thelle A, Gjerdevik M, SueChu M, Hagen OM, Bakke P. Randomised
comparison of needle aspiration and chest tube drainage in spontaneous
pneumothorax. Eur Respir J. 2017 Apr 12;49(4):1601296. Answer Key.
Article 4: Ramouz A, Lashkari MH, Fakour S, Rasihashemi SZ. Randomized
controlled trial on the comparison of chest tube drainage and needle aspiration in
the treatment of primary spontaneous pneumothorax. Pak J Med Sci. 2018 NovDec;34(6):1369-1374. Answer Key.
Bottom Line
While guidelines from both the British Thoracic Society and the American College of Chest Physicians recommend either aspiration or chest tube placement for initial management of primary spontaneous pneumothorax, many institutions utilize chest tube drainage exclusively in such cases. We sought to evaluate the evidence comparing simple aspiration with chest tube drainage to help determine the most appropriate management strategy for our patients. A systematic review and meta-analysis conducted by the Cochrane collaboration in 2017 identified 6 randomized controlled trials comprising 435 total patients with primary spontaneous pneumothorax who were randomized to aspiration or chest tube drainage. For their primary outcome, there was a statistically significant difference in immediate success rates favoring chest tube drainage (RR 0.78, 95% CI 0.69 to 0.89; I2 = 0%). “Immediate success” was defined by the individual study authors, but was defined as (near) complete lung expansion following simple aspiration in four studies with no time limit specified, and “complete success after the first attempt with discharge after 24 hours” in the fifth study to evaluate this outcome; in chest tube drainage groups, this was defined as complete expansion of the lung with absence of air, and chest tube removal within 72 hours after insertion. While immediate success rates were higher in the chest tube drainage group, hospital length of stay was significantly lower in the aspiration group (mean difference -1.66 days, 95% CI -2.28 to -1.04; I2 = 0%). There was no significant difference in “early failure rate” or one-year success. The studies included in this meta-analysis were limited primarily by lack of blinding of personnel and patients, which is understandable given the nature of the intervention. There were also issues in several studies with reporting of methodology, including failure to report methods of sequence generation and allocation concealment, and selective reporting. The authors conclude that the results suggest that aspiration is an attractive first-line treatment option for management of primary spontaneous pneumothorax, consistent with current guidelines. Since the literature search was performed for this meta-analysis, three additional randomized controlled trials have been performed. The first of these was conducted at three hospitals in Norway and enrolled 127 patients with both primary and secondary pneumothorax. The primary outcome, duration of hospital stay, was significantly longer in patients randomized to chest tube drainage (4.6 days, IQR 3 2.3-7.8) compared to those randomized to needle aspiration (2.4 days, IQR 1.2-4.7; p < 0.001). Immediate success rates were also higher in the needle aspiration group (68.8% vs. 31.8%; RR 2.17, 95% CI 1.45 to 3.22). There were no complications reported in the needle aspiration group, with 15 reported in the chest tube drainage group (wound infection in 4, bleeding in 2, subcutaneous emphysema in 7, pneumonia in 1, and empyema in 1). It should be noted that of 64 patients randomized to needle aspiration, 20 ultimately required chest tube placement. The next study was conducted in two hospitals in Iran in 2017 and 2018, and enrolled 70 patients with primary spontaneous pneumothorax, who were randomized 1:1 to either chest tube drainage or needle aspiration. There was no statistically significant difference in the immediate success of treatment between the chest tube drainage group and needle aspiration group (68.5% vs. 54.2%; RR 1.26, 95% CI 0.87 to 1.84). However, when a second aspiration was allowed following failure after 6 hours of observation, the success rate of needle aspiration increased to 91.4%. The mean duration of hospital stay was again longer in the CTD group compared to the NA group (mean difference 2.8 days, 95% CI 2.38 to 3.14). More recently, a much larger study was conducted at 31 centers in France between 2009 and 2015. This non-inferiority study enrolled 402 patients with spontaneous primary pneumothorax, and again randomized them in a 1:1 fashion to either simple aspiration or chest tube drainage. Aspiration was performed for 30 minutes, after which a repeat chest radiograph was performed; if this showed lung reexpansion, the aspiration device was removed and the patient was discharged after 24 hours of monitoring in the ED. If the pneumothorax persisted on repeat radiography, an additional 30 minutes of aspiration was performed followed by another repeat radiograph; if pneumothorax persisted at this point, chest tube drainage was performed and the patient was hospitalized. The primary outcome, failure of pulmonary expansion 24 hours after the procedure, was higher in the aspiration group than in the chest tube group in both the per-protocol analysis (risk difference [RD] 11.3; 95% CI 2.6% to 20%) and the intention to treat analysis (RD 9.7%; 95% CI 1.1% to 18.3%). However, the authors conclude that as neither of the two confidence intervals includes the fixed absolute margin of non-inferiority, aspiration is considered non-inferior to chest tube drainage for this outcome. Mean hospital length of stay was modestly lower in the aspiration group in the intention to treat analysis (mean difference -0.81 days, 95% CI -2.26 to – 0.64). As in the study from Norway, it must be noted that over a quarter of patients randomized to aspiration ultimately required chest tube drainage. This last and largest study confirms the findings in the Cochrane review, specifically that needle aspiration is associated with a higher initial failure rate (though the authors argue non-inferiority) and a shorter hospital length of stay. This difference in length of stay, while modest in the French paper, was still significant. Overall, these data suggest that primary aspiration is a reasonable first-line treatment for primary spontaneous pneumothorax in stable patients, with the caveat that the risks of failure, and ultimate need for chest tube placement, should be discussed with the patient prior to electing a course of action. By utilizing shared decision making, 4 clinicians will be better able to include patient values and preferences into their practice.