Comparative Effectiveness of Interventions in Initial Management of Spontaneous Pneumothorax: A Systematic Review and a Bayesian Network Meta-analysis.

STUDY OBJECTIVE: The best initial strategy for nontension symptomatic spontaneous pneumothorax is unclear. We performed a systematic review and meta-analysis to identify the most efficacious, safe, and efficient initial intervention in adults with nontension spontaneous pneumothorax.

METHODS: MEDLINE, Scopus, Web of Science, and ClinicalTrials.gov were searched from January 1950 through December 2019 (print and electronic publications). Randomized controlled trials evaluating needle aspiration, narrow-bore chest tube (<14 F) with or without Heimlich valve insertion, and large-bore chest tube (≥14 F) insertion in spontaneous pneumothorax were included. Network meta-analyses were performed with a Bayesian random-effects model.

RESULTS: Twelve studies were included in this review (n=781 patients). Analyses of efficacy (n=12 trials) revealed no significant differences between the interventions studied: narrow- versus large-bore chest tubes, odds ratio (OR) 1.05 (95% credible interval [CrI] 0.38 to 2.87); large-bore chest tube versus needle aspiration, OR 1.25 (95% CrI 0.65 to 2.62); and narrow-bore chest tube versus needle aspiration, OR 1.32 (95% CrI 0.54 to 3.42). Analyses of safety (n=10 trials) revealed a significant difference between needle aspiration and large-bore chest tube interventions: OR 0.10 (95% CrI 0.03 to 0.40). No differences were observed in needle aspiration versus narrow-bore chest tube (OR 0.29 [95% CrI 0.05 to 1.82]), and narrow- versus large-bore chest tube comparisons (OR 0.35 [95% CrI 0.07 to 1.67]). Analyses of efficiency were not pursued because of variation in reporting the length of stay (n=12 trials). Narrow-bore chest tube (<14 F) had the highest likelihood of top ranking in terms of immediate success (surface under the cumulative ranking curve=64%). Needle aspiration had the highest likelihood of top ranking in terms of safety (surface under the cumulative ranking curve=95.8%).

CONCLUSION: In the initial management of nontension spontaneous pneumothorax, the optimal strategy between the choices of a narrow-bore chest tube (<14 F, top ranked in efficacy) and needle aspiration (top ranked in safety) is unclear. Complications were more common in large-bore chest tube (≥14 F, including 14-F tube) insertions compared with needle aspiration.