Patient-Oriented Evidence That Matters

Watch-and-Wait Strategy Is an Option for Primary Spontaneous Pneumothorax


Am Fam Physician. 2020 Nov 15;102(9):online.

Clinical Question

Is conservative management effective for the treatment of uncomplicated primary spontaneous pneumothorax?

Bottom Line

Conservative observation of patients presenting with a first primary spontaneous pneumothorax is as effective as immediate chest tube insertion in achieving full lung re-expansion at eight weeks. Conservative therapy leads to fewer complications and fewer days in the hospital. (Level of Evidence = 1b−)


Patients who presented to the emergency departments of 39 hospitals in Australia and New Zealand with a unilateral, moderate to large, primary spontaneous pneumothorax were randomized to receive immediate inter vention (n = 154) or conservative observation (n = 162). In the intervention group, patients had a chest tube inserted (water seal for one hour, then clamped for four hours) and were monitored for re-expansion of the lung using chest radiography. If the lung re-expanded and the pneumothorax did not recur, then the chest tube was removed, and the patient was discharged. If the lung did not re-expand or the pneumothorax recurred, the patient was admitted to the hospital. In the conservative group, patients were observed for four hours. Patients whose symptoms were controlled, were walking comfortably, were hemodynamically stable without the need for supplemental oxygen, and had a stable pneumothorax on repeat chest radiography were discharged. Those who required further intervention were managed at the discretion of the treating physician. The mean age in the two groups was 26 years, and 86.1% of the patients were men. There were fewer current smokers in the conservative group (42.5% vs. 49.3%). At eight weeks, 98.5% of the intervention group and 94.4% of the conservative group had complete radiographic resolution of the pneumothorax, satisfying the prespecified noninferiority criteria of −9 percentage points (risk difference = −4.1 percentage points; 95% CI, −8.6 to 0.5; P = .02). Radiologists were less likely than

POEMs (patient-oriented evidence that matters) are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, see http://www.essentialevidenceplus.com. Copyright Wiley-Blackwell. Used with permission.

For definitions of levels of evidence used in POEMs, see http://www.essentialevidenceplus.com/product/ebm_loe.cfm?show=oxford.

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This series is coordinated by Sumi Sexton, MD, editor-in-chief.

A collection of POEMs published in AFP is available at https://www.aafp.org/afp/poems.



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