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Conservative versus Interventional Treatment for Spontaneous Pneumothorax.

Simon G A Brown1, Emma L Ball1, Kyle Perrin1

  • 1From the Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Royal Perth Hospital, and the University of Western Australia (S.G.A.B., E.L.B., C.A.R.), Royal Perth Hospital Imaging (K.V.L.) and the Respiratory Department (E.L.B., Q.A.S.), Royal Perth Hospital, the Department of Respiratory Medicine, Sir Charles Gairdner Hospital (Y.C.G.L.), and the Centre for Respiratory Health, School of Medicine and Pharmacology, University of Western Australia (Y.C.G.L.), Perth, Aeromedical and Retrieval Services, Ambulance Tasmania (S.G.A.B.), and the Department of Respiratory Medicine, Royal Hobart Hospital (E.L.B.), Hobart, the Emergency Department, St. George Hospital, Kogarah, NSW (S.E.A.), St. George Clinical School, Faculty of Medicine, University of New South Wales, Kensington (S.E.A., B.C.H.K.), the Emergency Department, Monash Medical Centre (D.E.-W.), the Departments of Medicine (D.E.-W.) and Surgery (J.A.S.), School of Clinical Sciences at Monash Health, Monash University, and the Department of Cardiothoracic Surgery, Monash Health (J.A.S.), Clayton, VIC, the Emergency Department, Gold Coast Health Service District, the School of Medicine, Bond University, and the School of Medicine, Griffith University, Gold Coast, QLD (G.K.), Emergency Medical and Children's Services, Prince Charles Hospital, Chermside, QLD (F.B.K.), the University of Queensland, Brisbane (F.B.K.), the Department of Respiratory and Sleep Medicine, Sutherland Hospital, Sydney (B.C.H.K.), and the Department of Respiratory Medicine, Cairns Hospital, Cairns, QLD (G.S.) - all in Australia; the Medical Research Institute of New Zealand (K.P., I.B., M.W., R.B.), the Capital and Coast District Health Board (K.P., M.W., R.B.), and Pacific Radiology (M.N.), Wellington, and the Adult Emergency Department, Auckland City Hospital and University of Auckland, Auckland (P.G.J.) - all in New Zealand.

The New England Journal of Medicine
|January 30, 2020
PubMed
Summary

Conservative management for primary spontaneous pneumothorax is comparable to interventional management. This approach showed noninferiority and a reduced risk of adverse events, offering a potentially safer alternative for patients.

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Area of Science:

  • Pulmonology
  • Thoracic Surgery
  • Emergency Medicine

Background:

  • The efficacy of conservative management versus interventional management for primary spontaneous pneumothorax (PSP) remains unclear.
  • Moderate-to-large PSP cases require evaluation for optimal treatment strategies.

Purpose of the Study:

  • To determine if conservative management is a noninferior alternative to interventional management for PSP.
  • To compare recurrence rates and adverse events between the two management strategies.

Main Methods:

  • An open-label, multicenter, noninferiority trial involved 316 patients aged 14-50 with unilateral, moderate-to-large PSP.
  • Patients were randomized to immediate interventional management or conservative observation.
  • The primary outcome was lung reexpansion within 8 weeks.

Main Results:

  • Complete-case analysis showed 98.5% reexpansion with interventional management vs. 94.4% with conservative management (risk difference: -4.1%; 95% CI, -8.6 to 0.5).
  • Sensitivity analysis with imputed data showed a risk difference outside the noninferiority margin.
  • Conservative management demonstrated a lower risk of serious adverse events and recurrence.

Conclusions:

  • Conservative management provides modest evidence of noninferiority to interventional management for PSP.
  • The conservative approach is associated with a reduced risk of serious adverse events.
  • Further consideration of conservative management is warranted for select PSP patients.