Ambulatory management of primary spontaneous pneumothorax: when less is more
Authors: Christopher Kapp, David Feller-Kopman
Journal: The Lancet (2020)

Spontaneous pneumothorax is a pneumothorax that occurs in the absence of trauma or iatrogenic injury, and occurs in about 20 000 people per year in the USA.1Feller-Kopman D Light R Pleural disease.N Engl J Med. 2018; 378: 740-751Crossref PubMed Scopus (105) Google Scholar Primary spontaneous pneumothorax is typically defined as a pneumothorax that occurs in patients without evidence of underlying lung disease, and is estimated to affect about 3000 people per year in the UK,2Hallifax RJ Goldacre R Landray MJ Rahman NM Goldacre MJ Trends in the incidence and recurrence of inpatient-treated spontaneous pneumothorax, 1968–2016.JAMA. 2018; 320: 1471-1480Crossref PubMed Scopus (46) Google Scholar whereas secondary pneumothorax occurs in patients with known lung disease such as emphysema, lymphangioleiomyomatosis, or Birt-Hogg-Dubé syndrome. It should be noted, however, that with the advent of CT imaging and advanced thoracoscopic techniques, underlying disease has been found to be present in a substantial number of people with primary spontaneous pneumothorax, thus bringing the importance of the dichotomy between primary and secondary spontaneous pneumothoraces into question.3Bintcliffe OJ Hallifax RJ Edey A et al.Spontaneous pneumothorax: time to rethink management?.Lancet Respir Med. 2015; 3: 578-588Summary Full Text Full Text PDF PubMed Scopus (69) Google Scholar Primary spontaneous pneumothorax has a bimodal age distribution, with young adults (aged 15–34 years) and older adults (aged ≥55 years) being the most commonly affected.4Gupta D Hansell A Nichols T Duong T Ayres JG Strachan D Epidemiology of pneumothorax in England.Thorax. 2000; 55: 666-671Crossref PubMed Scopus (250) Google Scholar Both the American College of Chest Physicians and the British Thoracic Society recommend intervention with either needle aspiration or tube thoracostomy as first-line treatment for large and symptomatic primary spontaneous pneumothorax.5Baumann MH Strange C Heffner JE et al.Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi Consensus Statement.Chest. 2001; 119: 590-602Summary Full Text Full Text PDF PubMed Scopus (802) Google Scholar, 6MacDuff A Arnold A Harvey J Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010.Thorax. 2010; 65: ii18-ii31Crossref PubMed Scopus (781) Google Scholar The British Thoracic Society provides a caveat that in large pneumothoraces in otherwise stable patients, conservative management with watchful waiting can be pursued.6MacDuff A Arnold A Harvey J Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010.Thorax. 2010; 65: ii18-ii31Crossref PubMed Scopus (781) Google Scholar Patients receiving a chest tube are typically in the hospital for at least 4 days, and commonly up to 8 days.7Thelle A Gjerdevik M SueChu M Hagen OM Bakke P Randomised comparison of needle aspiration and chest tube drainage in spontaneous pneumothorax.Eur Respir J. 2017; 491601296Crossref PubMed Scopus (37) Google Scholar, 8Schoenenberger RA Haefeli WE Weiss P Ritz RF Timing of invasive procedures in therapy for primary and secondary spontaneous pneumothorax.Arch Surg. 1991; 126: 764-766Crossref PubMed Scopus (97) Google Scholar Hospitalisation of otherwise healthy people for multiple days exposes patients to nosocomial complications and is associated with a loss of productivity in society. These effects have led researchers to consider less invasive methods of treating primary spontaneous pneumothorax. Conservative management without intervention, dubbed watchful waiting, has been evaluated with fairly consistent results, with up to 80–85% of patients not requiring further intervention.9Stradling P Poole G Conservative management of spontaneous pneumothorax.Thorax. 1966; 21: 145-149Crossref PubMed Scopus (73) Google Scholar, 10Brown SGA Ball EL Perrin K et al.Conservative versus interventional treatment for spontaneous pneumothorax.N Engl J Med. 2020; 382: 405-415Crossref PubMed Scopus (76) Google Scholar However, to be considered for conservative management, patients need to be clinically stable and have access to follow-up in case their symptoms worsen. Unfortunately, the data supporting conservative management consist primarily of small case series and potentially flawed randomised clinical trials with only short-term follow-up or radiographic (instead of patient-centred) endpoints.7Thelle A Gjerdevik M SueChu M Hagen OM Bakke P Randomised comparison of needle aspiration and chest tube drainage in spontaneous pneumothorax.Eur Respir J. 2017; 491601296Crossref PubMed Scopus (37) Google Scholar, 10Brown SGA Ball EL Perrin K et al.Conservative versus interventional treatment for spontaneous pneumothorax.N Engl J Med. 2020; 382: 405-415Crossref PubMed Scopus (76) Google Scholar In The Lancet, Rob Hallifax and colleagues11Hallifax RJ McKeown E Sivakumar P et al.Ambulatory management of primary spontaneous pneumothorax: an open-label, randomised controlled trial.Lancet. 2020; 396: 39-49Summary Full Text Full Text PDF PubMed Scopus (17) Google Scholar attempt to define the safety and efficacy of ambulatory management of patients with primary spontaneous pneumothorax. The investigators randomly assigned 236 patients with primary spontaneous pneumothorax who would typically receive intervention because they had a pneumothorax of 2 cm or more, significant symptoms, or both. Patients either received standard care (needle aspiration, tube thoracostomy, or both) or had an ambulatory small bore catheter (8F) with a one-way Heimlich valve inserted, the Rocket Pleural Vent (Rocket Medical, Watford, UK). The patients had a mean age of 30 years (SD 8) and 193 (82%) patients were male. Patients who met the predefined criteria for clinical stability, had a sufficient support structure at home, and could be followed up, were discharged with contact from the research team every 1–2 days. The study also included predefined criteria for lung re-expansion, fitness for discharge, and a priori criteria for failure of medical management. Patients were followed up for 12 months. Patients in the ambulatory group had a significantly reduced length of hospital stay in the first 30 days (median 0 days [IQR 0–3]) compared with the control group (4 days [0–8]; median difference 2 days, 95% CI 1–3 days; p<0·0001). Patients in the ambulatory group also had similar rates of readmission for treatment failure (17 [15%] of 117 patients) to the standard of care group (23 [19%] of 119 patients). Importantly, there was no difference in recurrence at 12 months, pain and breathlessness, or need for surgical referral. The ambulatory group did, however, have more adverse events (64 [55%] vs 46 [39%]), although most of these were related to increasing pneumothorax on subsequent chest imaging, prompting admission and chest tube insertion. Consistent with other trials, 24 (21%) of 114 patients in the ambulatory group with available data required an additional procedure, compared with 42 (35%) of 113 patients with available data in the standard of care group (p=0·0075). This is a well conducted trial that offers significant guidance on the management of clinically stable patients with primary spontaneous pneumothorax that is large enough to warrant intervention. The strengths of the study are the multicentre collaboration, predefined outcome measures, and use of patient-centred endpoints. As the authors note, a limitation of the study was their inability to enrol patients out of hours. In addition to the need to select patients who do not have barriers to follow-up, this factor might affect the ability to extrapolate to other populations and hospitals. Further studies with ambulatory devices are needed to confirm these results and improve the safety profile. At this time, ambulatory intervention should be considered for patients who can be followed up, and in hospital systems that have appropriate operational capacity to contact patients on a daily basis. We congratulate Hallifax and colleagues on their study, which shows an effective outpatient management option for patients with primary spontaneous pneumothorax. We declare no competing interests. Ambulatory management of primary spontaneous pneumothorax: an open-label, randomised controlled trialAmbulatory management of primary spontaneous pneumothorax significantly reduced the duration of hospitalisation including re-admissions in the first 30 days, but at the expense of increased adverse events. This data suggests that primary spontaneous pneumothorax can be managed for outpatients, using ambulatory devices in those who require intervention. Full-Text PDF Open Access