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Evidence in the ED: Can I just aspirate that spontaneous pneumothorax?

This study review evaluates the effectiveness, safety, and cost-effectiveness of manual aspiration versus chest tube drainage for patients with first episode spontaneous pneumothorax, based on prospective, randomized control trials.

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Evidence in the ED: Can I just aspirate that spontaneous pneumothorax?

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  1. Evidence in the ED:Can I just aspirate that spontaneous pneumothorax? Kevin R. Scott, M.D. Department of Emergency Medicine University of Pennsylvania

  2. References • Noppen M, et al. Manual aspiration versus chest tube drainage in first episodes of primary spontaneous pneumothorax: a multicenter, prospective, randomized pilot study. Am J RespirCrit Care Med. 2002 May 1;165(9):1240-4. • AyedAK, et al. Aspiration versus tube drainage in primary spontaneous pneumothorax: a randomised study. EurRespir J. 2006 Mar;27(3):477-82. • Parlak M, et al. A prospective, randomised trial of pneumothorax therapy: manual aspiration versus conventional chest tube drainage. Respir Med. 2012 Nov;106(11):1600-5.

  3. Noppen et al. 2002 Manual aspiration versus Chest Tube Drainage in First Episodes of Primary Spontaneous Pneumothorax: A Multicenter, Prospective, Randomized Pilot Study Am J RespirCrit Care Med. 2002 May 1;165(9):1240-4 Can I just tap that pneumothorax?

  4. Noppen et al. 2002 • Design: Prospective, randomized control trial • Population: • Included: 1st episode PSP, symptomatic, >20% of hemithorax • Excluded: underlying lung disease, previous ptx, tension ptx • Primary outcomes: Immediate success, 1-week success, 1-year success • Secondary outcomes: safety, hospitalization, duration of stay

  5. Noppen et al. 2002 • Manual Aspiration • 2nd or 3rd ICS at MCL with 16g catheter • 3-way valve and syringe for aspiration • Tube Thoracostomy • 16 or 20f tube at 4th or 5th ICS MAL • Placed to water seal or suction and removed after 24 hours of water seal • Follow-up included CXR at 48 hours if dc’d, 1 week and 2, 6, and 12 months

  6. Noppen et al. 2002 • Results: • 60 patients (MA=27, TT=33) • No significant difference in immediate success • 16/27 (59%) MA and 21/33 (63.6%) TT (p=0.90) • No difference in 1-week success and 1-year recurrence • Hospitalization occurred in 14/27 (52%) of MA group and 33/33 (100%) of TT group (p=<0.0001) • No difference in hospitalization duration • 3.41 ±1.56 days (MA) vs. 4.5 ±2.7 days (TT) • No urgent readmissions after discharge

  7. Noppen et al. 2002 • Conclusions: • MA and TT have similar immediate and long-term success • Given potential for outpatient management, MA may be more cost effective and therefore the preferable 1st line treatment in first episodes of PSP Aspiration of first-time PSP appears to be feasible, safe, and potentially cost effective, but larger studies are needed.

  8. Noppen et al. 2002 • Limitations • Underpowered • Does not directly study cost

  9. Ayed et al. 2006 Aspiration versus Tube Drainage in Primary Spontaneous Pneumothorax: A Randomized Study EurRespir J. 2006 Mar;27(3):477-82. Still looking for an answer…

  10. Ayed et al. 2006 • Design: Prospective, randomized control trial • Population: • Included: 1st episode PSP, symptomatic, >20% of hemothorax • Excluded: previous ptx, tension ptx, b/lptx, iatrogenic ptx, hemopneumothorax • Primary outcomes: Immediate success • Secondary outcomes: 1 week success, recurrence, safety, hospitalization, duration of stay, analgesia requirements, complications and inability to work

  11. Ayed et al 2006 • Manual Aspiration • 2nd ICS at MCL with 16g catheter • Water seal vacuum system • Tube Thoracostomy • 20f tube at 4th or 5th ICS MAL • Placed to suction and eventually removed after 24 hours of water seal • Follow-up included CXR at 1 week and 3, 6, 12 and 24 months

  12. Ayed et al 2006 • Results: • 208 patients enrolled and 137 randomized (MA=65, TT=72) • No significant difference in immediate success • 40/65 (62%) MA and 49/68 (68%) TT (p=0.90) • No difference in 1-week success or 3mo, 1yr, 2yr recurrence • Hospitalization occurred in 17/65 (26%) of MA group and 72/72 (100%) of TT group (p=<0.0001) • Significant difference in duration of stay • 1.85 ±3.9 days (MA) vs. 4 ±2.9 days (TT) (p=0.0003) • No readmission for recurrence or complications following MA

  13. Ayed et al 2006 • Conclusions: • MA and TT are equally effective and safe in treatment of 1st episode of PSP • MA is less painful, requires less hospitalization with shorter duration, demonstrates similar long term recurrence Aspiration again is as effective as TT. In addition, it less painful and results in shorter hospitalization if hospitalization is required. Again there is the suggestion that it might be more cost effective.

  14. Ayed et al 2006 • Limitations • Underpowered • Single center

  15. Parlak et al 2012 A Prospective, Randomized Trial of Pneumothorax Therapy: Manual Aspiration versus Conventional Chest Tube Drainage. RespirMed. 2012 Nov;106(11):1600-5. Is MA more cost effective (no studies)…so…does MA result in a shorter duration of hospitalization (potentially more cost effective)?

  16. Parlak et al 2012 • Design: Prospective, randomized control trial • Population: • Included: 18-85 years old, 1st episode symptomatic spontaneous or traumatic ptx, asymptomatic ptx >20% of hemithorax • Excluded: pregnancy, severe comorbidity, prior randomization, recurrent or tension ptx, limited decision making, chronic lung dz, HIV, Marfans • Primary outcomes: Duration of hospital stay • Secondary outcomes: immediate success rate, 2-week success, 1-year success, predictors for success

  17. Parlak et al 2012 • Manual Aspiration • 2nd or 3rd ICS at MCL with 1.3mm diameter catheter • 3-way valve and syringe for aspiration • No 2nd attempt • Tube Thoracostomy • 2nd/3rd ICS MCL • Placed to suction then to water seal after ceasing of air leak • Water seal x 4hours then CXR • Follow-up included CXR at 7 days s/p discharge and 1 year

  18. Parlak et al 2012 • Results: • 56 patients (MA=25, TT=31) • Duration of stay: MA 2.4 ±2.6 days, TT 4.4 ±3.3 days (p=0.02) • No significant difference in immediate success • 17/25 (68%) MA and 25/31 (80.6%) TT (p=0.28) • No difference in 2-week success or 1-year recurrence rates: • Predictors of immediate success included traumatic ptxand female gender

  19. Parlak et al 2012 • Conclusions: • MA shows no significant difference in success or recurrence in comparison to TT, but does result in a shorter duration of stay in the hospital. When compared to TT, MA has an associated shorter length of stay in the hospital and again demonstrates similar efficacy in the treatment of pneumothorax.

  20. Parlak et al 2012 • Limitations • Underpowered • 2000cc limit excluded success from MA in large ptx • Single center

  21. HUPism • Although MA appears to be safe, less painful, result in fewer hospitalizations and shorter durations of stay, and as effective as TT in the treatment of first time spontaneous PSP, there needs to be larger RCTs before substituting the catheter for the chest tube. • Perhaps a study demonstrating what may be a significant potential savings in healthcare costs using MA as first-line therapy for first-time PSP will be the driving force for a larger RCT leading to practice changes.

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