Chest Tube Drainage Versus Conservative Management as the Initial Treatment of Primary Spontaneous Pneumothorax: A Systematic Review and Meta-Analysis

Abstract

Objectives: This systematic review and meta-analysis aimed to compare chest tube drainage and conservative management as the initial treatment of primary spontaneous pneumothorax (PSP). Methods: Studies including PSP patients who received tube drainage or conservative management as the initial treatment were searched in OVID-MEDLINE and Embase through 14 February 2020. The primary outcome was the relative risk (RR) of PSP recurrence, and secondary outcomes were RRs of PSP resolution and adverse events during treatment. A random-effect model using the Mantel–Haenszel method was used to pool RRs. Subgroup and meta-regression analyses were performed to investigate significant predictors of PSP recurrence. Results: In total, 11,922 PSP cases from eight studies were analysed, of which 6344 were treated with tube drainage and 5578 were treated with conservative management. The pooled RR of PSP recurrence for conservative management against tube drainage was 0.98 (95% confidence interval [CI], 0.75–1.28; p = 0.894). Subgroup and meta-regression analyses revealed that study design (p = 0.816), allocation of the PSP amount in each management group (p = 0.191), and assessment time for recurrence had no significant impact on PSP recurrence (p = 0.816). There was no publication bias (p = 0.475). The risk of adverse events of conservative management was significantly lower than that of tube drainage (pooled RR, 0.22; 95% CI, 0.08–1.15; p = 0.003). However, no difference was found between the two groups in terms of PSP resolution (pooled RR, 1.01; 95% CI, 0.9–1.15; p = 0.814). Conclusions: As the initial treatment for PSP, conservative management is comparable to chest tube drainage in terms of PSP recurrence and resolution after treatment, with fewer adverse events during treatment.

An evidence‐based review of primary spontaneous pneumothorax in the adolescent population

“…97 The risk for repeated recurrences (ie, more than 1 recurrence) among patients with PSP treated non-surgically is also believed to be high, ranging from 40% to 83%. 95,[98][99][100][101] However, the referenced literature on the risk of repeated recurrences is based on an adult series that included elderly patients, with smoking rates ranging from 61% to 72%.…”

Understanding Primary Spontaneous Pneumothorax Management and Outcomes in Children: A Case Series

“…Recent evidence indicates that development of tension physiology is extremely rare in PSP and potentially not physiologically possible in a spontaneously breathing patient due to an inability for the pressure in the pneumothorax to exceed 1 standard atmospheric unit [28]. Combined, these findings support the consideration of observational management in the pediatric population [15,16].…”

“…A recent meta-analysis supports conservative management by demonstrating equivocal risk of PSP recurrence when comparing conservative management to tube thoracostomy. A lower risk of adverse events was demonstrated in the conservative management group with no difference noted in the rate of PSP resolution [16].…”

Expert Review on Spontaneous Pneumothorax: Advances, Controversies, and New Directions

“…The findings from Brown's study are supported by a systematic review published the same year 46 ; analysis of 10 papers, including Brown's, comparing conservative management with intervention found no difference between resolution rates, and noted lower risk of adverse events with patients managed conservatively. Interestingly this analysis found no difference in recurrence rates between conservative management and ICD insertion.…”