Simple aspiration versus intercostal tube drainage for primary spontaneous pneumothorax in adults

Kristin V Carson‐Chahhoud; Abel Wakai; Joep EM van Agteren; Brian J Smith; Grainne McCabe; Malcolm P Brinn; Ronan O'Sullivan

doi:10.1002/14651858.CD004479.pub3

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Figure 1

Study flow diagram.

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Figure 4

Forest plot of comparison: 1 Simple aspiration versus intercostal tube drainage, outcome: 1.1 Immediate success rate of procedure as defined by study authors.

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Analysis 1.1

Comparison 1 Simple aspiration versus intercostal tube drainage, Outcome 1 Immediate success rate of procedure as defined by study authors.

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Analysis 1.2

Comparison 1 Simple aspiration versus intercostal tube drainage, Outcome 2 Early failure rate of procedure (incomplete lung expansion after the procedure).

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Analysis 1.3

Comparison 1 Simple aspiration versus intercostal tube drainage, Outcome 3 One‐year success rate (number of participants with no recurrence of pneumothorax at 1 year).

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Analysis 1.4

Comparison 1 Simple aspiration versus intercostal tube drainage, Outcome 4 Hospitalization rate (number of participants hospitalized).

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Analysis 1.5

Comparison 1 Simple aspiration versus intercostal tube drainage, Outcome 5 Duration of hospital stay in days.

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Analysis 2.1

Comparison 2 Sensitivity analysis for risk of bias, Outcome 1 Hospitalization (number of participants hospitalized).

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Analysis 3.1

Comparison 3 Sensitivity analysis following visual inspection of data, Outcome 1 Hospitalization (number of participants hospitalized).

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Analysis 4.1

Comparison 4 Sensitivity analysis for studies with recurrent pneumothorax, Outcome 1 Immediate success rate of procedure as defined by study authors.

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Analysis 4.2

Comparison 4 Sensitivity analysis for studies with recurrent pneumothorax, Outcome 2 Early failure rate of procedure (incomplete lung expansion after the procedure).

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Analysis 4.3

Comparison 4 Sensitivity analysis for studies with recurrent pneumothorax, Outcome 3 One‐year success rate (number of participants with no recurrence of pneumothorax at 1 year).

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Analysis 4.4

Comparison 4 Sensitivity analysis for studies with recurrent pneumothorax, Outcome 4 Duration of hospital stay in days.

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Summary of findings for the main comparison. Simple aspiration compared with intercostal tube drainage for primary spontaneous pneumothorax

Simple aspiration compared with intercostal tube drainage for primary spontaneous pneumothorax
Patient or population: adults with primary spontaneous pneumothorax Settings: university teaching hospitals, tertiary care hospitals, and general hospitals Intervention: simple aspiration Comparison: intercostal tube drainage
Outcomes	Illustrative comparative risks (95% CI)		Relative effect (95% CI)	No. of participants (studies)	Quality of the evidence (GRADE)	Comments
Outcomes	Intercostal tube drainage	Simple aspiration	Relative effect (95% CI)	No. of participants (studies)	Quality of the evidence (GRADE)	Comments
Immediate success rate Follow‐up: 3 days to 24 months	714 per 1000	557 per 1000 (493 to 635)	RR 0.78 (0.69 to 0.89)	435 (6 studies)	⊕⊕⊕⊝ moderate^a
One‐year success rate Follow‐up: 12 to 24 months	766 per 1000	820 per 1000 (735 to 904)	RR 1.07 (0.96 to 1.18)	318 (4 studies)	⊕⊕⊕⊝ moderate^a
Hospitalization rate Follow‐up: 3 days to 24 months	862 per 1000	517 per 1000 (215 to 1000)	RR 0.60 (0.25 to 1.47)	245 (3 studies)	⊕⊝⊝⊝ very low^a,b,c
Duration of hospital stay Follow‐up: 12 to 24 months	Mean duration of hospital stay ranged across control groups from 4.04 to 7 days.	Mean duration of hospital stay in the intervention groups was 1.66 lower (‐2.28 to ‐1.04).	—	387 (5 studies)	⊕⊕⊕⊝ moderate^a
Adverse events Follow‐up: 3 days to 24 months	Overall, fewer adverse events occurred when patients were treated by simple aspiration than by tube drainage, including lesser perceived pain and lower pain scores, reduced need for thoracoscopic pleurodesis, and fewer technical adverse events (e.g. tube blockage when treated by tube drainage).		Not estimable	245 (3 studies)	⊕⊕⊝⊝ low^a,d
Cost‐effectiveness Not reported	See comment.	See comment.	Not estimable	‐	See comment.	No studies reported cost‐effectiveness data.
Patient satisfaction Follow‐up: mean 3 days	Median patient satisfaction among those treated with intercostal tube drainage was 8 on a visual analogue scale of 1 to 10 (Interquartile range 6.25 to 9.00), and median patient satisfaction among those treated by simple aspiration was 0.5 points lower (Interquartile range 5.00 to 9.00).			48 (1 study)	⊕⊕⊝⊝ low^a,e
CI: confidence interval; RR: risk ratio
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
^aResults for all outcomes downgraded one level as a result of study and/or reporting limitations, specifically, the large number of unclear or high risks of bias in the presented studies. ^bDowngraded one level as a result of significant heterogeneity (I² = 91%). ^cDowngraded one level as a result of imprecision: low numbers of events and large confidence intervals. ^dDowngraded one level as a result of inconsistency in and lack of reporting of adverse events. ^eDowngraded one level as a result of imprecision: reported by only one small study of 48 participants.

Summary of findings for the main comparison. Simple aspiration compared with intercostal tube drainage for primary spontaneous pneumothorax

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Comparison 1. Simple aspiration versus intercostal tube drainage

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Immediate success rate of procedure as defined by study authors Show forest plot	6	435	Risk Ratio (M‐H, Random, 95% CI)	0.78 [0.69, 0.89]

2 Early failure rate of procedure (incomplete lung expansion after the procedure) Show forest plot	6	427	Risk Ratio (M‐H, Random, 95% CI)	1.24 [0.91, 1.68]

3 One‐year success rate (number of participants with no recurrence of pneumothorax at 1 year) Show forest plot	4	318	Risk Ratio (M‐H, Random, 95% CI)	1.07 [0.96, 1.18]

4 Hospitalization rate (number of participants hospitalized) Show forest plot	3	245	Risk Ratio (M‐H, Random, 95% CI)	0.60 [0.25, 1.47]

5 Duration of hospital stay in days Show forest plot	5	387	Mean Difference (IV, Random, 95% CI)	‐1.66 [‐2.28, ‐1.04]

Comparison 1. Simple aspiration versus intercostal tube drainage

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Comparison 2. Sensitivity analysis for risk of bias

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Hospitalization (number of participants hospitalized) Show forest plot	3	245	Risk Ratio (M‐H, Random, 95% CI)	0.60 [0.25, 1.47]

1.1 Unclear risk of bias	1	60	Risk Ratio (M‐H, Random, 95% CI)	0.53 [0.37, 0.75]
1.2 Low risk of bias	2	185	Risk Ratio (M‐H, Random, 95% CI)	0.69 [0.10, 4.61]

Comparison 2. Sensitivity analysis for risk of bias

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Comparison 3. Sensitivity analysis following visual inspection of data

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Hospitalization (number of participants hospitalized) Show forest plot	3	245	Risk Ratio (M‐H, Random, 95% CI)	0.60 [0.25, 1.47]

1.1 All participants admitted for tube drainage	2	197	Risk Ratio (M‐H, Random, 95% CI)	0.38 [0.19, 0.76]
1.2 Not all participants admitted for tube drainage	1	48	Risk Ratio (M‐H, Random, 95% CI)	1.86 [0.89, 3.91]

Comparison 3. Sensitivity analysis following visual inspection of data

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Comparison 4. Sensitivity analysis for studies with recurrent pneumothorax

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Immediate success rate of procedure as defined by study authors Show forest plot	6	435	Risk Ratio (M‐H, Random, 95% CI)	0.78 [0.69, 0.89]

1.1 Recurrent primary spontaneous pneumothorax (PSP)	2	134	Risk Ratio (M‐H, Random, 95% CI)	0.69 [0.58, 0.82]
1.2 First episode PSP	4	301	Risk Ratio (M‐H, Random, 95% CI)	0.89 [0.75, 1.06]
2 Early failure rate of procedure (incomplete lung expansion after the procedure) Show forest plot	6	427	Risk Ratio (M‐H, Random, 95% CI)	1.24 [0.91, 1.68]

2.1 Recurrent PSP	2	126	Risk Ratio (M‐H, Random, 95% CI)	2.20 [0.11, 42.99]
2.2 First episode PSP	4	301	Risk Ratio (M‐H, Random, 95% CI)	1.28 [0.93, 1.77]
3 One‐year success rate (number of participants with no recurrence of pneumothorax at 1 year) Show forest plot	4	318	Risk Ratio (M‐H, Random, 95% CI)	1.07 [0.96, 1.18]

3.1 Recurrent PSP	1	65	Risk Ratio (M‐H, Random, 95% CI)	1.17 [0.90, 1.52]
3.2 First episode PSP	3	253	Risk Ratio (M‐H, Random, 95% CI)	1.05 [0.94, 1.17]
4 Duration of hospital stay in days Show forest plot	5	387	Mean Difference (IV, Random, 95% CI)	‐1.66 [‐2.28, ‐1.04]

4.1 Recurrent PSP	2	134	Mean Difference (IV, Random, 95% CI)	‐1.32 [‐3.31, 0.67]
4.2 First episode PSP	3	253	Mean Difference (IV, Random, 95% CI)	‐1.69 [‐2.40, ‐0.98]

Comparison 4. Sensitivity analysis for studies with recurrent pneumothorax

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