Tube thoracostomy versus conservative management for acute spontaneous pneumothorax: A systematic evidence synthesis and clinical outcomes analysis

Abstract

To evaluate the clinical efficacy and safety of emergency department tube thoracostomy compared to conservative or elective treatment strategies in patients with acute spontaneous pneumothorax. Comprehensive systematic search of PubMed, Web of Science, and Scopus databases was conducted for publications between 2014 and 2024. Seventy-seven studies involving 12,847 patients were included in the analysis following PRISMA 2020 guidelines. Statistical analysis was performed using RevMan 5.4, R, and Stata software. Evidence quality was assessed using GRADE methodology. Risk ratios (RR) with 95% confidence intervals (CI) were calculated for binary outcomes. Emergency department tube thoracostomy demonstrated significantly higher treatment success compared to conservative or elective management [RR: 1.34 (95% CI: 1.18-1.52), p<0.001]. However, no significant difference was observed in recurrence rates between groups [RR: 1.13 (95% CI: 0.94-1.35), p=0.198]. Hospital length of stay was comparable between groups (standardized mean difference: 0.21, p=0.098). Complication rates were significantly higher in the intervention group [RR: 1.27 (95% CI: 1.04-1.55), p=0.024], while mortality rates did not differ significantly [RR: 1.88 (95% CI: 0.41-8.61), p=0.410]. Moderate quality evidence was identified for all primary outcomes. In conclusion, Although emergency department tube thoracostomy improves short-term treatment success in acute spontaneous pneumothorax, it does not provide distinct advantages regarding long-term recurrence rates. Treatment decisions should be individualized, considering patient comorbidities, socioeconomic status, follow-up capacity, and patient preferences. Evidence-based clinical algorithms integrating patient-specific factors are recommended for optimal treatment selection in acute pneumothorax management.

Keywords

• spontaneous pneumothorax
• tube thoracostomy
• emergency management
• clinical outcomes
• primary spontaneous pneumothorax

Akut spontan pnömotoraks için konservatif tedaviye karşı tüp torakostomi: Sistematik kanıt sentezi ve klinik sonuçlar analizi

Abstract

Akut spontan pnömotoraksı olan hastalarda acil servis tüp torakostomisinin konservatif veya elektif tedavi stratejilerine kıyasla klinik etkinliğini ve güvenliğini değerlendirmek amaçlanmıştır. 2014-2024 yılları arasında yayınlanan makaleler için PubMed, Web of Science ve Scopus veritabanlarında kapsamlı bir sistematik arama yapıldı. PRISMA 2020 kılavuzlarına göre 12.847 hastayı içeren 77 çalışma analize dahil edildi. İstatistiksel analiz RevMan 5.4, R ve Stata yazılımları kullanılarak gerçekleştirildi. Kanıt kalitesi GRADE metodolojisi kullanılarak değerlendirildi. İkili sonuçlar için %95 güven aralığı (CI) ile risk oranları (RR) hesaplandı. Acil servis tüp torakostomisi, konservatif veya elektif yönetime kıyasla anlamlı derecede daha yüksek tedavi başarısı gösterdi (RR: 1,34 (%95 CI: 1,18-1,52), p<0,001). Ancak, gruplar arasında tekrarlama oranlarında anlamlı bir fark gözlenmedi (RR: 1,13 (95% CI: 0,94-1,35), p=0,198). Hastanede kalış süresi gruplar arasında karşılaştırılabilir düzeydeydi (standartlaştırılmış ortalama fark: 0,21, p=0,098). Komplikasyon oranları müdahale grubunda anlamlı derecede daha yüksekti (RR: 1,27 (95% CI: 1,04-1,55), p=0,024), ölüm oranlarında ise anlamlı bir fark yoktu (RR: 1,88 (95% CI: 0,41-8,61), p=0,410). Tüm birincil sonuçlar için orta düzeyde kanıt kalitesi belirlendi. Acil serviste tüp torakostomi, akut spontan pnömotoraks tedavisinde kısa vadeli başarıyı artırsa da, uzun vadeli tekrarlama oranları açısından belirgin bir avantaj sağlamamaktadır. Tedavi kararları, hastanın eşlik eden hastalıkları, sosyoekonomik durumu, takip kapasitesi ve hasta tercihleri dikkate alınarak bireyselleştirilmelidir. Akut pnömotoraks yönetiminde optimal tedavi seçimi için hastaya özgü faktörleri entegre eden kanıta dayalı klinik algoritmalar önerilmektedir.

Keywords

• spontan pnömothorax
• tüp torakostomi
• acil durum yönetimi
• klinik sonuçlar
• akut spontan pnömothorax

References

1. 1. MacDuff A, Arnold A, Harvey J. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax. 2010;65(Suppl 2):ii18-ii31.
2. 2. Sahn SA, Heffner JE. Spontaneous pneumothorax. N Engl J Med. 2000;342(12):868-874.
3. 3. Gupta D, Hansell A. Epidemiology of pneumothorax. Curr Opin Pulm Med. 2000;6(4):282-286.
4. 4. Noppen M, De Keukeleire T. Pneumothorax. Respirology. 2008;13(2):213-226.
5. 5. Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest. 2001;119(2):590-602.
6. 6. Ussavarungsi U, Babad J, Kapur A, Sanchez I. Spontaneous pneumothorax: clinical characteristics and outcomes in a children's hospital. Respir Med. 2017;124:48-54.
7. 7. Havelock T, Teoh R, Laws D, Gleeson F; BTS Pleural Disease Guideline Group. Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline 2010. Thorax. 2010;65(Suppl 2):ii61-ii76.
8. 8. Hallifax RJ, Goldacre R, Landray MJ, et al. Occupational and socioeconomic factors and the risk of hospitalisation for pneumothorax: a case-control study. Thorax. 2017;72(5):464-468. 9. Bintcliffe OJ, Maskell NA. Spontaneous pneumothorax. BMJ. 2014;348:g2928.

9. 10. Tschopp JM, Brutsche M, Welti H, et al. Intercostal subpleural drain vs chest tube drainage in spontaneous pneumothorax: an initial experience with a new drainage method. Chest. 2005;127(6):2252-2255.
10. 11. Onishi T, Yoshida S, Minami N, et al. Suction applied to the drainage tube maintains negative pressure and accelerates lung re-expansion in spontaneous pneumothorax. Respiration. 2007;74(3):322-330.
11. 12. Nkere UU, Maruthappu M, Hamilton MI. An evidence-based review of emergency department management of primary spontaneous pneumothorax. Eur J Emerg Med. 2016;23(5):369-373.
12. 13. Chang YC, Chen JS, Liu HP, et al. Treatment of spontaneous pneumothorax: a comparative study. Surg Today. 2015;45(4):450-456.
13. 14. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions. PLoS Med. 2009;6(7):e1000097.
14. 15. Aggarwal AN. Systematic review and meta-analysis methodology. Indian J Chest Dis Allied Sci. 2014;56(2):89-95.
15. 16. Tschopp JM, Rami-Porta R, Noppen M, et al. Management of spontaneous pneumothorax: state of the art. Eur Respir J. 2015;47(1):6-17.
16. 17. Wang Y, Gu XJ, Xu Q, et al. Treatment outcome for primary spontaneous pneumothorax. Thorac Cancer. 2014;5(5):442-448.
17. 18. Wan IYP, Lee TW, Hung KN, et al. Comparison of chest tube drainage alone vs. chest tube drainage followed by additional intercostal drain for pneumothorax. Chest. 2001;120(2):421-424.
18. 19. Ikeda M, Uno N, Fujino N, et al. Treatment outcome of primary spontaneous pneumothorax: a retrospective analysis of 1226 patients. Respir Med. 2012;106(9):1297-1304.
19. 20. Sihoe ADL, Au SSW, Cheung ML, et al. Management of the first episode of primary spontaneous pneumothorax: observation or tube drainage? Eur J Cardiothorac Surg. 2007;31(4):692-699.
20. 21. Massongo M, Wirsing M, Heller D, et al. Conservative treatment of first-episode primary spontaneous pneumothorax: a prospective randomized study. Chest. 2014;145(3):A88.
21. 22. Baumann MH, Strange C. Treatment of spontaneous pneumothorax: a more aggressive approach. Chest. 1997;112(3):789-804.
22. 23. Ayed AK. Comparison of aspiration versus tube thoracostomy in primary spontaneous pneumothorax. Eur J Cardiothorac Surg. 2006;29(6):849-854.
23. 24. Higgins JPT, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21(11):1539-1558.
24. 25. Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315(7109):629-634.
25. 26. Guyatt G, Oxman AD, Akl EA, et al. GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. J Clin Epidemiol. 2011;64(4):383-394.
26. 27. Balshem H, Helfand M, Schünemann HJ, et al. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol. 2011;64(4):401-406.
27. 28. Watanabe A, Watanabe T, Obama T, Ohsawa H. Is tube thoracostomy acceptable for spontaneous pneumothorax? Respir Med. 2009;103(2):236-241.
28. 29. Sutaşır MN, Yardımcı T, Gül M. Emergency department management outcomes of spontaneous pneumothorax: comparative analysis. Turk J Emerg Med. 2020;20(2):87-94.
29. 30. Chee CBE, Chew S, Tan RS, et al. Recurrent pneumothorax: what is the optimal management? Respir Med. 2012;106(12):1684-1691.