Surgery Unnecessary in Many Pneumothorax Cases

Laird Harrison

January 29, 2020

In many cases, collapsed lungs may recover better with conservative management than with surgery, researchers say.

Treatment for pneumothorax varies around the world, but most medical societies recommend some form of surgical intervention, generally involving the use of either a needle or a chest tube to drain the air and allow the lung to reexpand.

However, intervention of this kind is highly invasive, often extremely uncomfortable, and carries with it a risk for complications. Researchers and clinicians have long wondered whether it can be safely avoided in cases in which the patient has a spontaneous pneumothorax but is not in distress and has no underlying lung disease.

To find out more about the potential of conservative management as an alternative to surgical intervention, Simon Brown, MBBs, PhD, of the Harry Perkins Center for Clinical Research in Emergency Medicine in Nedlands, Australia, and colleagues conducted a randomized trial that included 316 patients with pneumothoraxes. Their findings were published online January 29 in the New England Journal of Medicine.

The researchers randomly assigned patients to either a surgical intervention group or a conservative management group. Patients in both groups were given analgesia consisting of acetaminophen, ibuprofen, and oral or intravenous opioids. For patients who were selected for intervention, a small-bore Seldinger-style chest tube was inserted into the patient's chest cavity to drain the air and reexpand the collapsed lung.

Clinicians observed for 4 hours those patients selected for conservative management and discharged them if they were walking comfortably and did not require supplementary oxygen. They operated on those patients with clinically significant symptoms that persisted despite analgesia, as well as on patients who asked not to continue with the conservative management treatment. During the study, 25 of the original 162 patients in the conservative management group underwent intervention.

The patients underwent unmasked clinical assessment between 24 and 72 hours after randomization and follow-up assessments 2 weeks, 4 weeks, and 8 weeks after treatment. Assessments took the form of a radiograph and a patient questionnaire. Radiographs were not performed if a previous radiograph had shown that the patient's lung had reexpanded. The researchers used telephone calls and clinical record searches to assess for recurrence 6 and 12 months after the patients had been assigned to the treatment groups.

After 63 days, 94.9% (129 of 136) of patients in the conservative management group reported resolution (reexpansion of the collapsed lung.) These results were only slightly inferior to those of patients who had undergone surgical intervention, of whom 98.5% (134 of 136) reported resolution within 63 days of treatment.

Even more surprising was the effect of conservative management on complications and reoccurrence. "Recurrence during the first 12 months was more frequent in the intervention group than in the conservative-management group: 25 of 149 patients (16.8%) as compared with 14 of 159 (8.8%)," the researchers explain.

The risk for complications was also lower in the conservative management group than it was in the surgical intervention group, with 41 patients who had undergone surgical intervention reporting at least one adverse event compared with only 13 patients in the conservative management group. In addition, patients in the conservative management group spent less time in the hospital (a mean of 1.6 days vs 6.1 days) and needed to take fewer days off from work (6.0 days vs 10.9 days) than their counterparts who underwent surgical intervention.

The reasons for the elevated risk for recurrence in the surgical intervention group are unknown. In an accompanying editorial, V. Courtney Broaddus, MD, professor of medicine at the University of California, San Francisco, postulates, "One possible explanation is that chest-tube drainage interfered with healing by pulling open the defect in the lung, whereas allowing the lung to reexpand slowly on its own permitted the defect to heal."

Broaddus notes that more research is needed regarding the efficacy of conservative management as a treatment for pneumothorax. But preliminary research indicates that in otherwise healthy patients, conservative management offers a safe and effective alternative to a risky and invasive surgery, she concludes.

Several authors have disclosed relationships with industry, a complete list of which is available on the journal's website.

N Engl J Med. Published online January 29, 2020.

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