Brief ReportA randomized controlled trial comparing minichest tube and needle aspiration in outpatient management of primary spontaneous pneumothorax☆
Introduction
Spontaneous pneumothorax is a relatively uncommon presenting problem at the emergency department (ED). The annual incidence of pneumothorax (both primary and secondary combined) was found to be 24/100 000 for men and 9.8/100 000 for women in a study originating from England, resulting in annual incidence of hospital admission of 16.7/100 000 for men and 5.8/100 000 for women [1]. The management of primary spontaneous pneumothorax varies by location. Traditional preference has been for chest tube insertion and admission to the ward. British Thoracic Society recommends needle aspiration (NA) as the initial treatment of choice [2], but American College of Chest Physicians Consensus prefers insertion of small-bore catheters (≤14F) or chest tubes (16-22F) [3].
Needle aspiration has been advocated as the first-line treatment for primary spontaneous pneumothorax because it has been found to be safe and less painful and leads to a shorter admission than chest tube insertion in randomized controlled trials [4], [5]. However, aspiration followed by immediate catheter removal was only successful in approximately 60% of patients, and more than half of these patients needed to be hospitalized [6].
Outpatient management of primary spontaneous pneumothorax with minichest tubes (MCTs) attached to Heimlich valve was touted as the procedure to address the lack of invasiveness of aspiration while avoiding the discomfort and costs of chest tube insertion [7]. This was found to be safe in a pilot study [8] and a retrospective case series [9]. However, they were limited by the retrospective and nonrandomized nature of the studies.
The aim of this study is to compare failure rate and admission rate associated with the use of NA and MCT in the outpatient management of primary spontaneous pneumothorax. The secondary outcomes of interest are complication rate, length of hospital stay, patient acceptability, and rate of full recovery during outpatient follow-up.
Section snippets
Design
The design of this study is a randomized controlled trial comparing NA and MCT (12F) insertion with Heimlich valve attachment in the treatment of primary spontaneous pneumothorax. Patients were randomized (blocked randomization using sealed envelopes) into 2 study arms. The patients were not stratified according to the size of the pneumothorax.
Patients in the MCT arm had MCT inserted in the ED by the resident under supervision by the attending emergency physician. The tube was connected to a
Results
During the period from January 2004 to December 2006, we recruited 48 consecutive patients with spontaneous pneumothorax (Table 1).
Twenty-three patients had NA. Three patients (13%) had complete reexpansion immediately after the procedure (Fig. 1). Eight patients (35%) required a second therapeutic procedure at the ED. Twelve patients (52%) were admitted from the ED (Fig. 2), of which 6 (26%) had thoracoscopic pleurodesis during admission. Both the mean and median number of days of admission
Discussion
Our results showed that most patients with primary spontaneous pneumothorax can be safely managed on an outpatient basis with either MCT or NA. In addition, there was a clinically important reduction of admissions from the ED by 72% with MCT and 48% with NA, although the difference was not statistically significant.
Both these procedures allowed many patients who would have been admitted previously to be managed safely in the ambulatory setting. Compared with the hitherto practice of admitting
Conclusion
Both MCT and NA allowed safe management of primary spontaneous pneumothorax in the outpatient setting. Both were equivalent in terms of failure rate, admission rate, pain score, satisfaction score, and complication rate. Among those who were successfully discharged from the ED, insertion of MCT attached to Heimlich valve was associated with a significantly higher rate of complete reexpansion of the pneumothorax at the first outpatient review.
Acknowledgments
The authors thank Dr Papia Sultana, Department of Clinical Research, Singapore General Hospital.
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Simple aspiration for spontaneous pneumothorax in adults: A systematic review and meta-analysis of randomized controlled trials
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Guidelines for management of patients with primary spontaneous pneumothorax
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Source of support: We acknowledge the support of the SingHealth Research Secretariat (CC032/2002) in providing the research grant.