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Consider Conservative Approach Rather Than Intervening in Moderate to Large Spontaneous Pneumothorax

      To the Editor:
      We noted the article on outcomes of needle aspiration versus chest tube placement for primary spontaneous pneumothorax by Tupchong.
      • Tupchong K.
      Update: is needle aspiration better than chest tube placement for the management of primary spontaneous pneumothorax?.
      We agree with Tupchong that the evidence in regard to the optimal management of primary spontaneous pneumothorax is limited and that chest tube placement is sometimes chosen because of unjustified fear of tension pneumothorax
      • Simpson G.
      • Vicent S.
      • Ferns J.
      Spontaneous tension pneumothorax: what is it and does it exist?.
      and is associated with significant adverse events. The article appropriately raises the question of how a less invasive approach such as needle aspiration performs in patients with moderate to large primary spontaneous pneumothorax.
      The less invasive approach of needle aspiration has been favored in randomized controlled trials for a variety of outcomes.
      • Parlak M.
      • Uil S.M.
      • van den Berg J.W.
      A prospective, randomised trial of pneumothorax therapy: manual aspiration versus conventional chest tube drainage.
      • Thelle A.
      • Gjerdevik M.
      • SueChu M.
      • et al.
      Randomised comparison of needle aspiration and chest tube drainage in spontaneous pneumothorax.
      The article concludes that the success rate is lower for needle aspiration, although immediate radiographic improvement may not be the only or most important measure of success.
      Overall, the review prompts clinicians to consider less invasive approaches to primary spontaneous pneumothorax. However, before one asks which intervention is most appropriate, one should consider the more important question of whether an intervention is required, because some patients with moderate to large primary spontaneous pneumothorax may be managed with a conservative approach.
      • Brown S.G.A.
      • Ball E.L.
      • Perrin K.
      • et al.
      Randomised controlled trial of invasive versus conservative management of primary spontaneous pneumothorax, a protocol.
      We have recently completed recruitment for what is to our knowledge the largest randomized controlled trial to date comparing intervention with observation alone in patients with primary spontaneous pneumothorax, and the outcomes of this study will be published later this year and provide clear direction for guidelines internationally.
      • Brown S.G.A.
      • Ball E.L.
      • Perrin K.
      • et al.
      Randomised controlled trial of invasive versus conservative management of primary spontaneous pneumothorax, a protocol.

      References

        • Tupchong K.
        Update: is needle aspiration better than chest tube placement for the management of primary spontaneous pneumothorax?.
        Ann Emerg Med. 2018; 72: e1-e2
        • Simpson G.
        • Vicent S.
        • Ferns J.
        Spontaneous tension pneumothorax: what is it and does it exist?.
        Intern Med J. 2012; 42: 1157-1160
        • Parlak M.
        • Uil S.M.
        • van den Berg J.W.
        A prospective, randomised trial of pneumothorax therapy: manual aspiration versus conventional chest tube drainage.
        Respir Med. 2012; 106: 1600-1605
        • Thelle A.
        • Gjerdevik M.
        • SueChu M.
        • et al.
        Randomised comparison of needle aspiration and chest tube drainage in spontaneous pneumothorax.
        Eur Respir J. 2017; 49: 1601296
        • Brown S.G.A.
        • Ball E.L.
        • Perrin K.
        • et al.
        Randomised controlled trial of invasive versus conservative management of primary spontaneous pneumothorax, a protocol.
        BMJ Open. 2016; 6: e011826

      Linked Article

      • Update: Is Needle Aspiration Better Than Chest Tube Placement for the Management of Primary Spontaneous Pneumothorax?
        Annals of Emergency MedicineVol. 72Issue 1
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          A total of 6 randomized controlled trials (435 patients) met inclusion criteria. Chest tube (12 to 20 French) placement had a higher immediate success rate but a longer hospital length of stay. There was no difference in 1-year success rate, hospitalization rate, or patient satisfaction. Needle aspiration had fewer adverse events. Meta-analyses were conducted only for immediate success rate and hospital length of stay (Table) because there was low or very low quality of evidence for all other outcomes.
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      • In reply:
        Annals of Emergency MedicineVol. 72Issue 6
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          I appreciate the Letter to the Editor from Keijzers et al1 because it raises an excellent point querying whether intervention should be performed in the first place for most patients with primary spontaneous pneumothoraces. This is an important dilemma not yet definitively addressed in the literature and one that clinicians at the bedside face before the question that the article2 attempts to answer.
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