High ASA-PS as an independent predictor of refractoriness and poor prognosis in secondary spontaneous pneumothorax

Secondary spontaneous pneumothorax (SSP) is a challenging disease with a poor prognosis, particularly in elderly patients with comorbidities, and its management is often difficult, sometimes leading to a refractory state. This study aimed to identify independent predictors for refractory Persistant Air Leakage (R-PAL) and evaluate respiratory disease-specific survival.

We retrospectively reviewed 292 patients treated for SSP between 2018 and 2024. R-PAL was strictly defined as an air leak persisting for 7 days following a definitive procedure. To adjust for treatment selection bias, we incorporated the initial treatment modality into our multivariate logistic regression and Cox proportional hazards models, directly comparing the predictive values of ASA-PS and ECOG-PS.

R-PAL occurred in 39 patients (13.4%). Multivariate logistic regression identified high ASA-PS (3) (Odds Ratio 6.13, p < 0.001) and non-surgical initial treatment (Odds Ratio 2.99, p = 0.007) as independent predictors of R-PAL. The ASA-PS model demonstrated superior fit and discrimination (AIC 183.4, AUC 0.84) compared to the ECOG-PS model. Furthermore, the 1-year respiratory disease-specific survival rate was significantly worse in the ASA-PS 3 group (67.4%) compared to the ASA-PS <3 group (98.0%). Cox analysis confirmed ASA-PS 3 as a significant independent predictor of mortality (Hazard Ratio 8.30, p = 0.007).

High ASA-PS independently predicts both refractoriness and poor prognosis in SSP, outperforming ECOG-PS. These findings suggest that physiological organ reserve is more critical for pleural healing than daily activity levels, necessitating a multidisciplinary approach for high-risk patients.