Observation, aspiration, or tube-thoracostomy for primary spontaneous pneumothorax: A systematic review, meta-analysis and cost-utility analysis.

BACKGROUND: Primary spontaneous pneumothorax (PSP) has several commonly used management strategies: observation, aspiration, and chest tube (CT). Economic modelling of pooled data comparing techniques has not been performed.

RESEARCH QUESTION: Based on studies from the past 20 years, approach to management of PSP delivers the highest utility?

STUDY DESIGN AND METHODS: A systematic review of PSP management strategies (observation, aspiration or CT) was conducted in Medline and EMBASE from January 1, 2000 to April 10, 2020. Text screening, bias assessment and data extraction was performed by two authors. Inclusion and exclusion criteria were defined a priori. The primary outcome was PSP resolution following the initial intervention. Secondary outcomes were PSP recurrence, length-of-stay, rate of surgical management, and complications. Meta-analysis compared treatment arms; dichotomous outcomes were reported as risk ratios (RR) and continuous outcomes as mean difference. A cost-utility analysis within the Canadian healthcare system context with deterministic and probabilistic sensitivity analyses were performed.

RESULTS: 5179 articles were identified; after screening, 22 articles were included. Most trials had high risk of bias but randomized trials were lower risk. Compared to CT, observation (Mean difference (MD):5.17, confidence interval (CI):3.75-6.59, p<0.01 I2 =62%) and aspiration (MD:2.72 CI:2.39-3.04, p<0.01, I2 =0%) had shorter length-of-stay. Compared to observation, CT (RR:0.81, CI:0.71-0.91, p<0.01, I2 =62%) and aspiration (RR:0.73, CI:0.61-0.88, p<0.01, I2 -=67%) had higher resolution without additional intervention. Two-year recurrence rates did not differ between management strategies. Observation had the best utility (0.82) and lowest cost; observation was the optimal strategy in 98.2% of Monte-Carlo simulations.

INTERPRETATION: Observation is the dominant choice compared to aspiration and CT for PSP. It should be considered as the first line therapy in appropriately selected patients.