Clinicians reluctant to adopt conservative management of pneumothorax

Despite an Australian trial supporting conservative management of primary spontaneous pneumothorax, clinicians in other countries appear to be awaiting updated guidelines from groups such as the European Respiratory Society (ERS) before moving away from interventional approaches, new research shows.

An online survey on the management of pneumothorax that received responses from 103 clinicians in the UK  (72% of whom were consultants), revealed significant variation in clinical practice.

Only half (51%) reported managing a large primary pneumothorax with minimal symptoms conservatively (observation with no intervention), and this fell to 3% if symptoms were ongoing.

“Similarly, only 19% would use an ambulatory device to manage a Primary Spontaneous Pneumothorax (PSP) with ongoing symptoms despite recent [trial] data suggesting ambulatory management is effective,” the authors noted in the paper, published in Respiratory Research.

Just over a quarter (28.2%) of respondents reported having an ambulatory pathway to manage pneumothorax, but a further 44% reported having plans to set up one in their hospital.

In other findings, despite existing guidelines suggesting initial treatment with needle aspiration (NA), only 36% in the survey said they would opt directly for chest drain insertion.

Around half (52%) of respondents said they always repeat a chest x-ray after chest drain removal compared to 19% who do not and 29% who sometimes do. Almost two thirds (64%) said they would use suction if the pneumothorax had not resolved after more than two days, and 15% said they would always clamp the chest drain before removal, while 30% reported never doing so.

While guidance from the National Institute for Health and Care Excellence (NICE) recommends use of digital suction, the study authors noted that his “has not translated into widespread usage”, as only 23% reported using digital suction to ensure that an air leak had been resolved.

The study authors noted that a 2020 randomised controlled trial carried out in Australia and New Zealand provided evidence that conservative management was noninferior to interventional management for radiographic resolution of moderate-to-large primary spontaneous pneumothorax within eight weeks.

The RCT, published in the NEJM, showed that conservative management “spared 85% of the patients from an invasive intervention and incurred fewer days in the hospital or off from work, lower rates of surgery, and a lower risk of serious adverse events or pneumothorax recurrence than interventional management.”

But according to the authors, the optimal initial treatment regime for primary spontaneous pneumothorax (PSP) was still not well defined in guidelines published by the European Respiratory Society (ERS) in 2015 and the British Thoracic Society (BTS) in 2010.

The guidelines are due to be updated, and the treatment paradigm may be changed by results of recently-published RCTs, said study author Professor Najib Rahman, a Consultant Respiratory and Pleural Physician at the Oxford Centre for Respiratory Medicine, and Director of the Oxford Respiratory Trials Unit at Oxford University.

“Conservative management is an important treatment choice in some patients who are minimally symptomatic with PSP,” he told the limbic.

“Ambulatory management works well and allows reduced time in hospital in PSP”, but is “less effective and potentially hazardous in SSP and should be used with caution,” he added.

According to the authors: “Whilst there has always been allowance for individual clinician preference in guidelines, there needs to be consensus on the optimum management strategy. The challenge the new guidelines face is to design a simple and pragmatic approach, using this new evidence base.”

“Further data and the updated ERS and BTS guidelines are eagerly awaited. The real test, however, will be in the future education and implementation,” they stressed.

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