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Three Part Question

In [a young patient with a spontaneous pneumothorax without tension] is [needle aspiration or chest drainage] better at [reinflating the lung, reducing hospital stay and preventing recurrence]?

Clinical Scenario

A 25 year old patient with no history of respiratory disease attends the Emergency Department with acute onset of shortness of breath. A chest x-ray reveals a left-sided pneumothorax of approximately 50% the volume of the left lung; there is no tension. You wonder whether needle aspiration or chest drain insertion is the treatment of choice.

Search Strategy

Medline 1966-03/99 using the OVID interface.
({exp pneumothorax OR pneumothora$} AND {exp aspiration OR aspiration.mp OR thoracocentesis.mp} AND {exp chest tubes OR drainage OR exp thoracostomy OR chest drain$.mp}) LIMIT to human and english language.

Search Outcome

83 papers found of which 81 were irrelevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Harvey J and Prescott RJ 1995 UK	73 patients with spontaneous pneumothorax. Needle aspiration (35) vs intercostal drain (38)	PRCT	Success rate	80% vs 100%	Small numbers. Large differences in groups at baseline in terms of size of pneumothorax (34% vs 58% complete collapse)
			Pain score during procedure	No significant difference
			Hospital stay	3.2 vs 5.3 days (P = 0.005)
			Recurrence rate	No significant difference
Andrivet P et al 1995 France	61 patients with first or second episode of spontaneous pneumothorax. Needle aspiration (33) vs thoracic drainage (28)	RCT	Success rate	61% vs 93% (P = 0.01)	Small numbers Hospital stay prolonged in needle aspiration group as procedure not carried out for 72 h in most patients.
			Hospital stay	No significant difference
			Recurrence rate by 3 months	No significant difference

Comment(s)

In these flawed, small studies needle aspiration is shown to be useful in some cases. However the failure rate is high and aspiration cannot therefore be thought of as a single complete treatment for this condition. Further studies are required to confirm the decrease in length of stay in the aspiration group.

Clinical Bottom Line

Needle aspiration may be carried out as the first treatment of spontaneuos pneumthoraces without tension. Patients must then be observed as subsequent intercostal drainage may be necessary.

References

1. Harvey J, Prescott RJ. Simple aspiration versus intercostal tube drainage for spontaneous pneumothorax in patients with normal lungs. BMJ 1994;309(6965):1338-1339.
2. Andrivet P, Djedaini K, Teboul JL et al. Spontaneous pneumothorax. Comparison of thoracic drainage vs immediate or delayed needle aspiration. Chest 1995;108(2):335-339.